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Cleaver J, Jeffery K, Klenerman P, Lim M, Handunnetthi L, Irani SR, Handel A. The immunobiology of herpes simplex virus encephalitis and post-viral autoimmunity. Brain 2024; 147:1130-1148. [PMID: 38092513 PMCID: PMC10994539 DOI: 10.1093/brain/awad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/25/2023] [Accepted: 11/27/2023] [Indexed: 04/06/2024] Open
Abstract
Herpes simplex virus encephalitis (HSE) is the leading cause of non-epidemic encephalitis in the developed world and, despite antiviral therapy, mortality and morbidity is high. The emergence of post-HSE autoimmune encephalitis reveals a new immunological paradigm in autoantibody-mediated disease. A reductionist evaluation of the immunobiological mechanisms in HSE is crucial to dissect the origins of post-viral autoimmunity and supply rational approaches to the selection of immunotherapeutics. Herein, we review the latest evidence behind the phenotypic progression and underlying immunobiology of HSE including the cytokine/chemokine environment, the role of pathogen-recognition receptors, T- and B-cell immunity and relevant inborn errors of immunity. Second, we provide a contemporary review of published patients with post-HSE autoimmune encephalitis from a combined cohort of 110 patients. Third, we integrate novel mechanisms of autoimmunization in deep cervical lymph nodes to explore hypotheses around post-HSE autoimmune encephalitis and challenge these against mechanisms of molecular mimicry and others. Finally, we explore translational concepts where neuroglial surface autoantibodies have been observed with other neuroinfectious diseases and those that generate brain damage including traumatic brain injury, ischaemic stroke and neurodegenerative disease. Overall, the clinical and immunological landscape of HSE is an important and evolving field, from which precision immunotherapeutics could soon emerge.
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Affiliation(s)
- Jonathan Cleaver
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Katie Jeffery
- Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, OX1 3SY, UK
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Ming Lim
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
- Department Women and Children’s Health, School of Life Course Sciences, King’s College London, London, WC2R 2LS, UK
| | - Lahiru Handunnetthi
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
| | - Adam Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
- Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, OX3 9DU, UK
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Bakht A, Lantz P, Harrison W. HSV-associated chronic granulomatous encephalitis in a child. J Neuropathol Exp Neurol 2024; 83:205-208. [PMID: 38219251 DOI: 10.1093/jnen/nlad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Affiliation(s)
- Azad Bakht
- Department of Laboratory Medicine and Pathology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Hospital, Winston Salem, North Carolina, USA
| | - Patrick Lantz
- Department of Laboratory Medicine and Pathology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Hospital, Winston Salem, North Carolina, USA
| | - William Harrison
- Department of Laboratory Medicine and Pathology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Hospital, Winston Salem, North Carolina, USA
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3
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Xie L, Lu A, Wang X, Cheng B, Zhu X, Hu H. Herpes simplex virus type 2 encephalitis in a child with chronic progressive white matter lesions: A case report. Medicine (Baltimore) 2022; 101:e32289. [PMID: 36550828 PMCID: PMC9771169 DOI: 10.1097/md.0000000000032289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE This case is a rare manifestation of central nervous system infection of Herpes simplex virus (HSV)-2. Due to few studies in China, it provides a pathological basis for further diagnosis and treatment of HSV-2. PATIENT CONCERNS We describe a patient with HSV-2 virus infection who was diagnosed with HSV-2 encephalitis in a Chinese patient. DIAGNOSIS Based on brain biopsy and pathological findings, the patient was diagnosed with HSV-2 encephalitis. INTERVENTIONS Hormone and antiviral therapy were given. OUTCOME The patient eventually died. LESSONS The diagnosis and differential diagnosis of the disease is very difficult. Its differential diagnosis include cerebrovascular disease, bacteria or fungi and other viral infection of the brain.
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Affiliation(s)
- Lei Xie
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Aijun Lu
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | | | - Bihong Cheng
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Xuemin Zhu
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Huaiqiang Hu
- The 960th Hospital of PLA, Jinan, China
- * Correspondence: Hu, Huaiqiang, The 960th Hospital of PLA, Jinan, China (e-mail: )
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4
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McKenna B, Malone C, Merwe A, Kathirvelu G, Mankad K. Granulomatous Herpetic Encephalitis A Possible Role for Inflammasomes. J Child Neurol 2022; 37:359-365. [PMID: 35060810 DOI: 10.1177/08830738221074497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Granulomatous herpetic encephalitis is a rare inflammatory complication of acute herpes simplex encephalitis. METHODS We describe 3 cases of granulomatous herpetic encephalitis in children arising between 1 to 10 years after the initial presentation with acute herpes simplex encephalitis. We focus on the clinical course and neuroimaging phenotype with a discussion of possible mechanisms underpinning this entity. RESULTS The clinical course was highly variable. However, the dominant neuroimaging phenotype in each of our cases was that of confluent gyriform cortical enhancement with predominantly solid foci of enhancement in the subjacent white matter +/- deep gray nuclei. Cerebrospinal fluid was negative for herpes simplex virus DNA in all cases. All 3 cases required brain biopsy to help establish the diagnosis. CONCLUSIONS Increased recognition of granulomatous herpetic encephalitis in children will facilitate earlier diagnosis and treatment. Although the exact role played by the host immune response, genetics, and environment in determining the different outcomes of herpes simplex encephalitis remains to be determined, we postulate a role for inflammasome dysregulation in this entity.
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Affiliation(s)
- Brendan McKenna
- Neuroradiology Department, 156556Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - Caitlin Malone
- Radiology Department, 156555Royal Victoria Hospital, Belfast, United Kingdom
| | - Ashirwad Merwe
- Neuropathology Department, 4956Great Ormond Street Hospital, London, United Kingdom
| | | | - Kshitij Mankad
- Department of Paediatric Neuroradiology, Great Ormond Street Hospital for Children, London, United Kingdom
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O'Brien CA, Bennett FC, Bennett ML. Microglia in antiviral immunity of the brain and spinal cord. Semin Immunol 2022; 60:101650. [PMID: 36099864 PMCID: PMC9934594 DOI: 10.1016/j.smim.2022.101650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 01/15/2023]
Abstract
Viral infections of the central nervous system (CNS) are a significant cause of neurological impairment and mortality worldwide. As tissue resident macrophages, microglia are critical initial responders to CNS viral infection. Microglia seem to coordinate brain-wide antiviral responses of both brain resident cells and infiltrating immune cells. This review discusses how microglia may promote this antiviral response at a molecular level, from potential mechanisms of virus recognition to downstream cytokine responses and interaction with antiviral T cells. Recent advancements in genetic tools to specifically target microglia in vivo promise to further our understanding about the precise mechanistic role of microglia in CNS infection.
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Affiliation(s)
- Carleigh A O'Brien
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States.
| | - F Chris Bennett
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States; Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | - Mariko L Bennett
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States; Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States
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6
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Sehl-Ewert J, Schwaiger T, Schäfer A, Hölper JE, Klupp BG, Teifke JP, Blohm U, Mettenleiter TC. Clinical, neuropathological, and immunological short- and long-term feature of a mouse model mimicking human herpes virus encephalitis. Brain Pathol 2021; 32:e13031. [PMID: 34709694 PMCID: PMC9048517 DOI: 10.1111/bpa.13031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/13/2021] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
Herpes simplex encephalitis (HSE) is one of the most serious diseases of the nervous system in humans. However, its pathogenesis is still only poorly understood. Although several mouse models of predominantly herpes simplex virus 1 (HSV-1) infections mimic different crucial aspects of HSE, central questions remain unanswered. They comprise the specific temporofrontal tropism, viral spread within the central nervous system (CNS), as well as potential molecular and immunological barriers that drive virus into latency while only rarely resulting in severe HSE. We have recently proposed an alternative mouse model by using a pseudorabies virus (PrV) mutant that more faithfully represents the striking features of human HSE: temporofrontal meningoencephalitis with few severely, but generally only moderately to subclinically affected mice as well as characteristic behavioral abnormalities. Here, we characterized this animal model using 6- to 8-week-old female CD-1 mice in more detail. Long-term investigation over 6 months consistently revealed a biphasic course of infection accompanied by recurring clinical signs including behavioral alterations and mainly mild meningoencephalitis restricted to the temporal and frontal lobes. By histopathological and immunological analyses, we followed the kinetics and spatial distribution of inflammatory lesions as well as the underlying cytokine expression in the CNS over 21 days within the acute phase of infection. Affecting the temporal lobes, the inflammatory infiltrate was composed of lymphocytes and macrophages showing a predominantly lymphocytic shift 15 days after infection. A strong increase was observed in cytokines CXCL10, CCL2, CCL5, and CXCL1 recruiting inflammatory cells to the CNS. Unlike the majority of infected mice, strongly affected animals demonstrated extensive temporal lobe edema, which is typically present in severe human HSE cases. In summary, these results support the validity of our animal model for in-depth investigation of HSE pathogenesis.
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Affiliation(s)
- Julia Sehl-Ewert
- Department of Experimental Animal Facilities and Biorisk Management, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Theresa Schwaiger
- Institute of Immunology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany.,ViraTherapeutics GmbH, Rum, Austria
| | - Alexander Schäfer
- Institute of Immunology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Julia E Hölper
- Institute of Immunology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany.,Institute of Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Barbara G Klupp
- Institute of Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Jens P Teifke
- Department of Experimental Animal Facilities and Biorisk Management, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Ulrike Blohm
- Institute of Immunology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
| | - Thomas C Mettenleiter
- Institute of Molecular Virology and Cell Biology, Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
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Abstract
INTRODUCTION The typical herpes simplex viral encephalitis (HSVE) course is an acute illness, less commonly it may present as a chronic course, mainly in children, and rarely may it be subacute. Subacute HSVE is rarely described in the literature being reported 4 times only. CASE REPORT We here report 2 cases of subacute HSV1 encephalitis diagnosed based on cerebrospinal fluid polymerase chain reaction and magnetic resonance imaging findings and review the literature trying to find any specific clinical, laboratory, radiologic diagnostic or prognostic criteria regarding this subacute form of HSVE. CONCLUSION There is subacute form of HSVE and should be suspected with any subacute febrile illness with nonspecific cognitive impairment even in the absence of focal neurological symptoms and in cases with rapidly progressive dementia. This form has similar radiologic finding and good response to acyclovir but carry even better prognosis than that the acute HSVE.
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8
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Manzano GS, Danish HH, Chu CJ, Kimchi EY. Child Neurology: Intractable Epilepsy and Transient Deficits in a Patient With a History of Herpes Simplex Virus Encephalitis. Neurology 2021; 96:679-681. [PMID: 33495374 DOI: 10.1212/wnl.0000000000011606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Giovanna S Manzano
- From the Department of Neurology, Massachusetts General Hospital, Boston.
| | - Husain H Danish
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Catherine J Chu
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Eyal Y Kimchi
- From the Department of Neurology, Massachusetts General Hospital, Boston
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9
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Management and results of epilepsy surgery associated with acyclovir prophylaxis in four pediatric patients with drug-resistant epilepsy due to herpetic encephalitis and review of the literature. Eur J Paediatr Neurol 2020; 29:128-136. [PMID: 32868196 DOI: 10.1016/j.ejpn.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Herpes simplex virus encephalitis (HSE) is the most common cause of sporadic viral encephalitis in children and is responsible for epilepsy in approximately half of patients. In addition to medical treatment, epilepsy surgery may be offered to drug-resistant patients but carries a high risk of relapse of herpetic encephalitis. We are reporting our series of patients operated on between 2000 and 2019 with the systematic administration of acyclovir (ACV). RESULTS Four pediatric patients aged 4.5-12.8 years with drug-resistant epilepsy post-HSE underwent a tailored focal resection following invasive recordings (three patients) and a complete callosotomy (one patient). The total number of the surgical procedures for the four patients was eight, and a systematic administration of ACV as a prophylactic treatment of herpetic encephalitis relapse was done at each step. No patients had a relapse and the ACV was well-tolerated in all the cases. Following surgery two patients are seizure free, the patient who underwent callosotomy is Engel 3 and the fourth patient, in whom a large epileptic zone has contraindicated a second surgery, is Engel 4. CONCLUSIONS Our series demonstrated the dramatic efficacy of systematic ACV prophylaxis during all cranial surgeries. Moreover, our results on epilepsy, together with those of the literature, encourage more consideration regarding epilepsy surgery in this specific etiology. All types of surgical procedures (curative or palliative) can be offered to the patients, but in the case of focal surgery, due to the poor anatomical limits, invasive recordings are highly recommended.
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10
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Iwai Y, Nishimura K, Fukushima T, Ito T, Watanabe Y, Noro M, Kuwabara S. An Adult Case of Herpes Simplex Virus-associated Granulomatous Encephalitis. Intern Med 2019; 58:1491-1494. [PMID: 30626834 PMCID: PMC6548933 DOI: 10.2169/internalmedicine.2046-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Brain granuloma occurs under certain conditions. Herpes simplex virus (HSV) causes granulomatous encephalitis in children; however, it has been rarely reported in adults. A 74-year-old man with a history of herpes simplex encephalitis suffered recurrent seizures. Brain magnetic resonance imaging revealed a mass lesion and resection was performed. A polymerase chain reaction using a brain biopsy specimen was positive for HSV DNA; thus, the patient was diagnosed with HSV-associated granulomatous encephalitis. After administering acyclovir, the patient showed improvement. HSV can cause granulomatous encephalitis in adults, and acyclovir can be used for its treatment.
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Affiliation(s)
- Yuta Iwai
- Department of Neurology, Matsudo City General Hospital, Japan
| | | | | | - Takashi Ito
- Department of Neurology, Matsudo City General Hospital, Japan
| | | | - Masahiro Noro
- Department of Pathology, Matsudo City General Hospital, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
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Childs L, Lim G, Thompson A, Bates TR, Kho LK, Phatouros C. A rare suspected case of chronic nodular granulomatous herpes simplex encephalitis in an adult. BJR Case Rep 2018; 4:20170114. [PMID: 31489214 PMCID: PMC6711280 DOI: 10.1259/bjrcr.20170114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/09/2022] Open
Abstract
Herpes simplex encephalitis is the most common sporadic viral encephalitis in the
western world, HSV-1 (herpes simplex virus) being the mostly commonly implicated
serotype. The disease is usually monophasic, although patients may relapse
weeks, months or years after initial infection. This chronic granulomatous
inflammatory process is almost exclusively described in children and rarely
forms discrete enhancing parenchymal nodules. We present the clinical and
radiological features of an unusual case of chronic nodular granulomatous herpes
encephalitis with enhancing “mass-like” nodules in an adult. To
the author’s knowledge, this is the first reported case of macroscopic
“mass-like” nodular granuloma formation in an adult.
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Affiliation(s)
- Lucy Childs
- Neurological Imaging and Intervention Service Western Australia (NIISwa), Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Guan Lim
- Neurological Imaging and Intervention Service Western Australia (NIISwa), Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Andrew Thompson
- Neurological Imaging and Intervention Service Western Australia (NIISwa), Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Timothy R Bates
- Stroke Unit, Swan District Hospital, Midland, WA, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Lay Kun Kho
- Department of Neurology, Royal Perth Hospital, Perth, WA, Australia
| | - Constantine Chris Phatouros
- Neurological Imaging and Intervention Service Western Australia (NIISwa), Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Taskin BD, Tanji K, Feldstein NA, McSwiggan-Hardin M, Akman CI. Epilepsy surgery for epileptic encephalopathy as a sequela of herpes simplex encephalitis: case report. J Neurosurg Pediatr 2017; 20:56-63. [PMID: 28452654 DOI: 10.3171/2017.3.peds16632] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Herpes simplex virus (HSV) encephalitis can manifest with different clinical presentations, including acute monophasic illness and biphasic chronic granulomatous HSV encephalitis. Chronic encephalitis is much less common, and very rare late relapses are associated with intractable epilepsy and progressive neurological deficits with or without evidence of HSV in the cerebrospinal fluid. The authors report on an 8-year-old girl with a history of treated HSV-1 encephalitis when she was 13 months of age and focal epilepsy when she was 2 years old. Although free of clinical seizures, when she was 5, she experienced behavioral and academic dysfunction, which was later attributed to electrographic focal seizures and worsening electroencephalography (EEG) findings with electrical status epilepticus during slow-wave sleep (ESES). Following a right temporal lobectomy, chronic granulomatous encephalitis was diagnosed. The patient's clinical course improved with the resolution of seizures and EEG abnormalities.
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Affiliation(s)
- Birce Dilge Taskin
- Department of Pediatric Neurology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey; and
| | - Kurenai Tanji
- Department of Pathology and Cell Biology, Division of Neuropathology
| | | | | | - Cigdem I Akman
- Department of Neurology, Division of Child Neurology, Columbia University Medical Center, New York
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Varatharaj A, Nicoll JA, Pelosi E, Pinto AA. Corticosteroid-responsive focal granulomatous herpes simplex type-1 encephalitis in adults. Pract Neurol 2017; 17:140-144. [PMID: 28153849 DOI: 10.1136/practneurol-2016-001474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2016] [Indexed: 11/04/2022]
Abstract
We describe corticosteroid-responsive focal granulomatous encephalitis as a manifestation of herpes simplex virus (HSV) type 1 disease in the brain: something easily missed and easily treated. Two adult cases presented with cognitive symptoms progressing over weeks, despite aciclovir treatment. Brain imaging showed temporal lobe abnormalities, with gadolinium enhancement but no abnormal diffusion restriction. HSV-1 PCR analysis was negative in cerebrospinal fluid (CSF) but positive in brain biopsies, which showed vasocentric granulomatous inflammation. Paired blood and CSF samples showed intrathecal synthesis of HSV-1 type-specific IgG. The patients improved clinically only after immunosuppression. Despite profound cognitive impairment at their clinical nadir, both patients recovered fully. We suggest that, at least in a subset of patients with HSV-1 encephalitis, adjunctive corticosteroid treatment is critical to improve the outcome of the disease.
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Affiliation(s)
- Aravinthan Varatharaj
- Clinical Neurosciences, University of Southampton, Southampton, UK .,Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James Ar Nicoll
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Emanuela Pelosi
- Department of Microbiology and Virology, Public Health England Regional Laboratory, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ashwin A Pinto
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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14
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Chronic herpes simplex type-1 encephalitis with intractable epilepsy in an immunosuppressed patient. Infection 2015; 44:121-5. [PMID: 26187268 DOI: 10.1007/s15010-015-0822-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/06/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Chronic herpes simplex virus type-1 encephalitis (HSE-1) is uncommon. Past reports focused on its association with prior documented acute infection. Here, we describe a patient with increasingly intractable epilepsy from chronic HSE-1 reactivation without history of acute central nervous system infection. CASE PRESENTATION A 49-year-old liver transplant patient with 4-year history of epilepsy after initiation of cyclosporine developed increasingly frequent seizures over 3 months. Serial brain magnetic resonance imaging showed left temporoparietal cortical edema that gradually improved despite clinical decline. Herpes simplex virus type-1 (HSV-1) DNA was detected in cerebrospinal fluid by polymerase chain reaction. Cerebrospinal fluid HSV-1&2 IgM was negative. Seizures were controlled after acyclovir treatment, and the patient remained seizure free at 1-year follow-up. CONCLUSION Chronic HSE is a cause of intractable epilepsy, can occur without a recognized preceding acute phase, and the clinical course of infection may not directly correlate with neuroimaging changes.
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15
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Schutz PW, Fauth CT, Al-Rawahi GN, Pugash D, White VA, Stockler S, Dunham CP. Granulomatous herpes simplex encephalitis in an infant with multicystic encephalopathy: a distinct clinicopathologic entity? Pediatr Neurol 2014; 50:392-6. [PMID: 24485930 DOI: 10.1016/j.pediatrneurol.2013.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 12/01/2013] [Accepted: 12/07/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Herpes simplex virus encephalitis can manifest as a range of clinical presentations including classic adult, neonatal, and biphasic chronic-granulomatous herpes encephalitis. METHOD We report an infant with granulomatous herpes simplex virus type 2 encephalitis with a subacute course and multicystic encephalopathy. CASE A 2-month-old girl presented with lethargy and hypothermia. Computed tomography scan of the head showed multicystic encephalopathy and calcifications. Cerebrospinal fluid analysis by polymerase chain reaction testing for herpes simplex virus 1 and 2, enterovirus, and cytomegalovirus was negative. Normal cerebrospinal fluid interferon-α levels argued against Aicardi-Goutières syndrome. The patient died 2 weeks after presentation. At autopsy, multicystic encephalopathy was confirmed with bilateral gliosis, granulomatous inflammation with multinucleated giant cells, and calcifications. Bilateral healing necrotizing retinitis suggested a viral etiology, but retina and brain were free of viral inclusions and immunohistochemically negative for herpes simplex virus-2 and cytomegalovirus. However, polymerase chain reaction analysis showed herpes simplex virus-2 DNA in four cerebral paraffin blocks. Subsequent repeat testing of the initial cerebrospinal fluid sample using a different polymerase chain reaction assay was weakly positive for herpes simplex virus-2 DNA. CONCLUSION Granulomatous herpes simplex virus encephalitis in infants can present with subacute course and result in multicystic encephalopathy with mineralization and minimal cerebrospinal fluid herpes simplex virus DNA load. Infectious etiologies should be carefully investigated in the differential diagnosis of multicystic encephalopathy with mineralization, in particular if multinucleated giant cells are present.
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Affiliation(s)
- Peter W Schutz
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.
| | - Clarissa T Fauth
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada; Department of Pathology, Red Deer Regional Hospital, Red Deer, Canada
| | - Ghada N Al-Rawahi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada; Department of Pathology and Laboratory Medicine, Children's and Women's Health Centre of British Columbia, Vancouver, Canada
| | - Denise Pugash
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Valerie A White
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada; Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Sylvia Stockler
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Christopher P Dunham
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada; Department of Pathology and Laboratory Medicine, Children's and Women's Health Centre of British Columbia, Vancouver, Canada
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Chronic granulomatous herpes encephalitis in a child with clinically intractable epilepsy. Case Rep Pediatr 2012; 2012:849812. [PMID: 22919528 PMCID: PMC3420097 DOI: 10.1155/2012/849812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 06/07/2012] [Indexed: 01/29/2023] Open
Abstract
Most patients with herpes simplex virus Type I encephalitis experience an acute, monophasic illness. Chronic encephalitis is much less common, and few late relapses are associated with intractable seizure disorders. A 10-year-old boy was admitted to our institution for intractable epilepsy as part of an evaluation for epilepsy surgery. His history was significant for herpes meningitis at age 4 months. At that time, he presented to an outside hospital with fever for three days, with acyclovir treatment beginning on day 4 of his 40-day hospital course. He later developed infantile spasms and ultimately a mixed seizure disorder. Video electroencephalogram showed a Lennox-Gastaut-type pattern with frequent right frontotemporal spikes. Imaging studies showed an abnormality in the right frontal operculum. Based on these findings, he underwent a right frontal lobectomy. Neuropathology demonstrated chronic granulomatous inflammation with focal necrosis and mineralizations. Scattered lymphocytes, microglial nodules and nonnecrotizing granulomas were present with multinucleated giant cells. Immunohistochemistry for herpes simplex virus showed focal immunoreactivity. After undergoing acyclovir therapy, he returned to baseline with decreased seizure frequency. This rare form of herpes encephalitis has only been reported in children, but the initial presentation of meningitis and the approximate 10-year-time interval in this case are unusual.
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17
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Adamo MA, Abraham L, Pollack IF. Chronic granulomatous herpes encephalitis: a rare entity posing a diagnostic challenge. J Neurosurg Pediatr 2011; 8:402-6. [PMID: 21961549 DOI: 10.3171/2011.7.peds10393] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Herpesviruses can cause an acute, subacute, or chronic disease state in both immunocompetent and immunocompromised individuals. Herpes simplex virus (HSV) encephalitis is most often an acute monophasic disease process. Rarely, however, it may progress to a chronic state, and more rarely still to a granulomatous encephalitis. Prior studies have suggested that antiviral immunity with Toll-like receptors determines susceptibility to herpesviruses. The authors report the case of a 14-year-old girl with a remote history of treated HSV encephalitis, who had intractable seizures and worsening MR imaging changes that were concerning for either a neoplastic or an inflammatory process. She was found to have granulomatous herpes simplex encephalitis and had a low cytokine response to Toll-like receptor 3 stimulation.
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Affiliation(s)
- Matthew A Adamo
- Division of Neurosurgery, Albany Medical Center, Albany, New York, USA
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Brown WD, Bearer EL, Donahue JE. Chronic active herpes simplex type 2 encephalitis in an asymptomatic immunocompetent child. J Child Neurol 2010; 25:901-8. [PMID: 20179002 PMCID: PMC3376078 DOI: 10.1177/0883073809353449] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A unique form of chronic, active, granulomatous herpes simplex type 2 encephalitis is described in an asymptomatic, immunocompetent 8-year-old girl who acquired the virus as a neonate. The extensive, bilateral cerebral parenchymal involvement was discovered incidentally. Diagnosis was confirmed by a combination of serial neuroimaging, brain biopsy, and quantitative polymerase chain reaction targeted to DNA sequences in the glycoprotein G gene, allowing differentiation between herpes simplex virus types 1 and 2. The clinical course over a 5-year period, treatment with intermittent intravenous steroids, and daily valacyclovir, diagnostic imaging, and laboratory studies are reviewed in detail. This form of herpes simplex virus type 2 encephalitis hasn't been described previously and is significant because of its prolonged indolent course, absence of neurological findings or suggestive history, and benign behavior in this child, who is now 14 years old. The authors believe this entity can be unsuspected and underdiagnosed in the general pediatric population, especially in those with a prior maternal history of herpes simplex virus type 2 infection.
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Affiliation(s)
- William D. Brown
- Warren Alpert Medical School at Brown University, Providence, RI, Department of Pediatrics and Department of Neurology, Hasbro Children’s Hospital/Rhode Island Hospital, Providence, RI
| | - Elaine L. Bearer
- Warren Alpert Medical School at Brown University, Providence, RI, Department of Pathology, University of New Mexico Medical School, Albuquerque, NM
| | - John E. Donahue
- Warren Alpert Medical School at Brown University, Providence, RI, Department of Pathology (Neuropathology) and Clinical Neurosciences (Neurology), Rhode Island Hospital, Providence, RI
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Tokumaru AM, Kamakura K, Terada H, Kobayashi O, Kanemaru A, Kato T, Murayam S, Yamakawa M, Mizuno M. Asymptomatic self-limiting diffuse white matter lesions in subacute to chronic stage of herpes simplex encephalitis. Neuroradiol J 2008; 21:316-22. [PMID: 24256899 DOI: 10.1177/197140090802100304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 03/13/2008] [Indexed: 11/17/2022] Open
Abstract
This study evaluated white matter changes in the subacute and chronic stages of herpes simplex encephalitis (HSE). Subjects comprised 15 patients with HSE. All patients were examined using MRI at onset, and then at seven to ten days, three to five weeks and two to three months after onset. In addition, the six patients who displayed white matter signal abnormalities were examined at six months and <one year after onset. Cell count, protein levels, polymerase chain reaction (PCR) of herpes simplex virus in cerebrospinal fluid (CSF), and exacerbation of neurological symptoms as well as dose of acyclovir were compared between patients with and without white matter abnormalities. Diffuse white matter signal changes were identified at the subacute stage (3-5 weeks after onset) of HSE in six patients (6/15, 40%). No significant relationship was observed between the presence of white matter signal abnormalities and laboratory data, acyclovir dose or clinical symptoms. These signal abnormalities disappeared or improved by two years without any clinical treatment. Diffuse white matter signal abnormalities occur frequently in the subacute stage of HSE. Although the mechanisms underlying these white matter lesions have not been elucidated, subclinical immune-mediated processes may be considered. Repeat MRI studies over a long period are necessary for evaluating the clinical process of patients with HSE.
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Affiliation(s)
- A M Tokumaru
- Department of Radiology, Tokyo Metropolitan Medical Center of Gerontology; Tokyo, Japan -
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20
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Bulakbasi N, Kocaoglu M. Central nervous system infections of herpesvirus family. Neuroimaging Clin N Am 2008; 18:53-84; viii. [PMID: 18319155 DOI: 10.1016/j.nic.2007.12.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Herpesviruses are one of the most common groups of pathogens causing central nervous system infections in humans. They mostly cause encephalitis, meningitis, or myelitis in immunocompetent and immunocompromised patients. Children, adults, and the elderly can all be affected. Although contrast-enhanced CT is more widely used for diagnosis, contrast-enhanced MR imaging combined with diffusion-weighted imaging is superior to CT in the detection of early changes and the real extent of the disease, and in assessing prognosis and monitoring response to antiviral treatment. More sophisticated techniques, such as MR spectroscopy and perfusion imaging, can aid in the differential diagnosis of herpesvirus infections from other tumoral, demyelinating, and ischemic processes.
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Affiliation(s)
- Nail Bulakbasi
- Department of Radiology, Gulhane Military Medical Academy and School of Medicine, Etlik, Ankara 06018, Turkey.
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21
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De Tiège X, Rozenberg F, Héron B. The spectrum of herpes simplex encephalitis in children. Eur J Paediatr Neurol 2008; 12:72-81. [PMID: 17870623 DOI: 10.1016/j.ejpn.2007.07.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/05/2007] [Accepted: 07/10/2007] [Indexed: 11/19/2022]
Abstract
Clinical and basic science research carried out in recent years into herpes simplex encephalitis (HSE) have shown that the concept of a "classical" picture of HSE in children is now outdated and that our current knowledge of the disease is probably only the tip of an iceberg. Indeed, increasing evidence supports the existence of a wider range of pathophysiological mechanisms, clinical presentations and disease progressions in paediatric HSE. This paper reviews the clinical, biological and radiological data available and redefines the spectrum of HSE in children. Full understanding of the condition should improve the management of suspected cases and decrease the morbidity and the mortality associated with this disease.
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Affiliation(s)
- Xavier De Tiège
- Department of Paediatric Neurology, ULB-Hôpital Erasme, Brussels, Belgium.
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22
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Viñas JMP, Gonzalez MJM, Ribes AG, Expósito RG, Bragado FG. Postencephalitic chronic granulomatous disease. Pediatr Neurol 2006; 35:297-9. [PMID: 16996409 DOI: 10.1016/j.pediatrneurol.2006.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Revised: 03/28/2006] [Accepted: 05/11/2006] [Indexed: 11/17/2022]
Abstract
This report details the evolution of a case of herpes simplex encephalitis to chronic granuloma in a 13-year old female who, at the age of 8, suffered herpes simplex virus type 1 encephalitis. Eight months later, she developed an intracranial hypertension syndrome with the onset of a new lesion in the necrosed zone of her right temporal lobe, with no viral presence in the cerebrospinal fluid. The histologic characteristics were those of chronic granuloma with multinucleated giant cells and calcifications. Initially treated for neurosarcoidosis, the patient remained steroid-dependent for 4 years and the steroids could only be withdrawn by treatment with Infliximab. This type of evolutive pattern has probably been completely overlooked until now; it can only be accurately diagnosed by biopsy. It was initially mistaken for neurosarcoidosis.
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Shuper A, Michovitz S, Amir J, Kornreich L, Boikov O, Yaniv Y, Rorke-Adams LB. Idiopathic granulomatous encephalitis mimicking malignant brain tumor. Pediatr Neurol 2006; 35:280-3. [PMID: 16996404 DOI: 10.1016/j.pediatrneurol.2006.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Revised: 01/20/2006] [Accepted: 04/14/2006] [Indexed: 10/24/2022]
Abstract
Idiopathic granulomatous encephalitis is a rare disorder of unknown etiology, undetermined treatment, and often grave prognosis. This article describes a 4-year-old female who presented with a single focal febrile convulsion followed a few weeks later by right-sided hemiparesis. A huge infiltrative cerebral mass tumor was found which proved to be a granuloma on histologic study. Despite a thorough evaluation, including tissue studies and search for an infectious agent, no etiology could be identified, and the final diagnosis was idiopathic granulomatous encephalitis. Recurrent resections and high-dose steroid treatment failed to control the process, and the patient died of disease 6 months after presentation. Evaluation and treatment of idiopathic granulomatous encephalitis should be aggressive, and the possibility of chemotherapy and perhaps even radiotherapy should be considered if there is no response to steroids.
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Affiliation(s)
- Avinoam Shuper
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv Univ., Israel, and Department of Neuropathology, The Children's Hospital of Philadelphia, PA, USA.
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24
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Leen WG, Weemaes CM, Verbeek MM, Willemsen MA, Rotteveel JJ. Chronic herpes simplex virus encephalitis in childhood. Pediatr Neurol 2006; 35:57-61. [PMID: 16814088 DOI: 10.1016/j.pediatrneurol.2005.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 09/02/2005] [Accepted: 12/19/2005] [Indexed: 10/24/2022]
Abstract
Although herpes simplex virus is a major cause of acute encephalitis in childhood, chronic herpes simplex virus encephalitis has only rarely been reported. This report presents a case of chronic herpes simplex virus encephalitis in a 6-year-old female. Diagnosis was based on the detection of herpes simplex virus deoxyribonucleic acid by polymerase chain reaction in combination with the cerebrospinal fluid/serum ratio of herpes simplex virus-specific immunoglobulin G, the presence of herpes simplex virus-specific oligoclonal immunoglobulin G bands in cerebrospinal fluid, and calcifications in the temporal regions found on cerebral computed tomographic scan. Prolonged antiviral therapy was beneficial to later mental development.
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Affiliation(s)
- Wilhelmina G Leen
- Department of Pediatric Neurology, University Medical Centre St Radboud, Nijmegen, The Netherlands
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