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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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Grezenko H, Zafar F, Nathaniel E, Aguirre G, Baluch SK, Abubakar M. Navigating Neurological and Cardiac Complexities: A Case Study on Viral Meningoencephalitis in a Patient With Ischemic Heart Disease. Cureus 2024; 16:e52763. [PMID: 38389596 PMCID: PMC10882189 DOI: 10.7759/cureus.52763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
We present a case of viral meningoencephalitis in a 40-year-old male with ischemic heart disease, a combination that is rare and presents unique diagnostic and therapeutic challenges. The patient's symptoms included high-grade fever, severe headache, projectile vomiting, and altered consciousness. The diagnosis was supported by MRI and CSF analysis. Management, complicated by the patient's cardiac condition, required a personalized approach, including antiviral therapy, corticosteroids, and vigilant monitoring of cardiac and neurological status. Treatment adjustments were made in response to the patient's evolving condition, leading to improvement within a week. This case underscores the need for a multidisciplinary approach in such complex scenarios, highlighting the significance of tailored care for patients with neurological symptoms and concurrent cardiac comorbidities. The report contributes to the literature on managing meningoencephalitis in patients with significant cardiac histories, underscoring personalized medicine's role in successful outcomes.
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Affiliation(s)
- Han Grezenko
- Translational Neuroscience, Barrow Neurological Institute, Phoenix, USA
| | | | | | - Guillermo Aguirre
- Internal Medicine, Ignacio A. Santos School of Medicine, Ciudad de México, MEX
| | - Shariq K Baluch
- Internal Medicine, Universidad Autonoma de Guadalajara, Guadalajara, MEX
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Van Den Tooren H, Easton A, Hooper C, Mullin J, Fish J, Carson A, Nicholson T, Solomon T, Michael BD. How should we define a 'good' outcome from encephalitis? A systematic review of the range of outcome measures used in the long-term follow-up of patients with encephalitis. Clin Med (Lond) 2022; 22:145-148. [PMID: 38589176 DOI: 10.7861/clinmed.2021-0505] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Encephalitis is typically caused by infection or autoimmunity. Most survivors suffer complex neurological and psychiatric sequelae. Standardised outcome measures are needed for accurate interpretation of observational studies and clinical trials. Step one in this process is understanding the strengths and weaknesses of those in use. METHODS We performed a systematic literature review searching six databases. One reviewer screened titles and abstracts, and two reviewers determined if shortlisted full-text articles met inclusion criteria. Key data were extracted from these papers and presented as a narrative summary. RESULTS Thirty-seven outcome measures were used for 3,133 patients across the 35 included papers, of which, only one was developed for encephalitis. The outcome measures used in most patients were the Glasgow Outcome Score used in 1,436 (46%), Barthel Index used in 1,173 (37%), Euro-QoL-5D used in 1,107 (35%) and modified Rankin Scale used in 1,034 (33%). CONCLUSION Most of the 37 measures assessed a single category of sequelae using 5-8-point scales and were not validated for use in encephalitis. Research is needed to develop a composite outcome measure for use in clinical practice and a core-outcomes set for use in clinical trials. For now, the Liverpool Outcome Score offers a good choice for clinicians.
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Affiliation(s)
| | - Ava Easton
- Encephalitis Society, Malton, UK and honorary lecturer, University of Liverpool, Liverpool, UK
| | - Cory Hooper
- The Walton Centre NHS Foundation Trust, Liverpool, UK and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, UK
| | - Jenny Mullin
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | | | | | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, UK and honorary consultant neurologist, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Benedict D Michael
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infection, Liverpool, Liverpool, UK and consultant neurologist, The Walton Centre NHS Foundation Trust, Liverpool, UK.
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Wijesinghe VN, Farouk IA, Zabidi NZ, Puniyamurti A, Choo WS, Lal SK. Current vaccine approaches and emerging strategies against herpes simplex virus (HSV). Expert Rev Vaccines 2021; 20:1077-1096. [PMID: 34296960 DOI: 10.1080/14760584.2021.1960162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Vaccine development for the disease caused by the herpes simplex virus (HSV) has been challenging over the years and is always in dire need of novel approaches for prevention and cure. To date, the HSV disease remains incurable and challenging to prevent. The disease is extremely widespread due to its high infection rate, resulting in millions of infection cases worldwide.Areas covered: This review first explains the diverse forms of HSV-related disease presentations and reports past vaccine history for the disease. Next, this review examines current and novel HSV vaccine approaches being studied and tested for efficacy and safety as well as vaccines in clinical trial phases I to III. Modern approaches to vaccine design using bioinformatics are described. Finally, we discuss measures to enhance new vaccine development pipelines for HSV.Expert opinion: Modernized approaches using in silico analysis and bioinformatics are emerging methods that exhibit potential for producing vaccines with enhanced targets and formulations. Although not yet fully established for HSV disease, we describe current studies using these approaches for HSV vaccine design to shed light on these methods. In addition, we provide up-to-date requirements of immunogenicity, adjuvant selection, and routes of administration.
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Affiliation(s)
| | - Isra Ahmad Farouk
- School of Science, Monash University, Bandar Sunway, Selangor, Malaysia
| | | | | | - Wee Sim Choo
- School of Science, Monash University, Bandar Sunway, Selangor, Malaysia
| | - Sunil Kumar Lal
- School of Science, Monash University, Bandar Sunway, Selangor, Malaysia.,Tropical Medicine & Biology Platform, Monash University, Bandar Sunway, Selangor, Malaysia
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Hilario GM, Sulczewski FB, Liszbinski R, Mello LD, Hagen G, Fazolo T, Neto J, Dallegrave E, Romão P, Aguirre T, Rodrigues Junior LC. Development and immunobiological evaluation of nanoparticles containing an immunodominant epitope of herpes simplex virus. IET Nanobiotechnol 2021; 15:532-544. [PMID: 34694744 PMCID: PMC8675790 DOI: 10.1049/nbt2.12043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/19/2022] Open
Abstract
Herpes simplex virus (HSV) 1 and 2 are viruses that infect individuals worldwide and for which there is no cure or vaccine available. The protective response against herpes is mostly mediated by CD8 T lymphocytes that respond to the immunodominant SSIEFARL epitope. However, there are some obstacles concerning the use of free SSIEFARL for vaccine or immunotherapy. The aim of this study was to evaluate the feasibility of nanoencapsulation of SSIEFARL and its immunostimulatory properties. Nano/SSIEFARL was produced by interfacial polymerization in methylmetacrylate, and the physico-chemical properties, morphology and immunobiological parameters were evaluated. To evaluate the ex vivo capacity of Nano/SSIEFARL, we used splenocytes from HSV-1-infected mice to enhance the frequency of SSIEFARL-specific CD8 T lymphocytes. The results indicate that Nano/SSIEFARL has a spherical shape, an average diameter of 352 ± 22 nm, the PDI was 0.361 ± 0.009 and is negatively charged (-26.30 ± 35). The stability at 4°C was 28 days. Also, Nano/SSIEFARL is not toxic for cells at low concentrations in vitro and it is taken up by JAWS II dendritic cells. No histopathological changes were observed in kidneys, liver and lymph nodes of animals treated with Nano/SSIEFARL. Nan/SSIEFARL increased the production of IL-1β, TNF-α and IL-12 by the dendritic cells. Finally, Nano/SSIEFARL expanded the frequency of SSIEFARL-specific CD8+T lymphocytes at the same rate as free SSIEFARL. In conclusion all data together indicate that SSIEFARL is suitable for nanoencapsulation, and the system produced presents some immunoadjuvant properties that can be used to improve the immune response against herpes.
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Affiliation(s)
- Gabriel M Hilario
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Fernando B Sulczewski
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Raquel Liszbinski
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Larissa D Mello
- Laboratório de Nanotecnologia, Universidade Franciscana, Brazil
| | - Gustavo Hagen
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Tiago Fazolo
- Laboratório de Imunologia Celular e Molecular, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Jayme Neto
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Eliane Dallegrave
- Laboratório de Pesquisa em Toxicologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Pedro Romão
- Laboratório de Imunologia Celular e Molecular, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Tanira Aguirre
- Laboratório de Imunoterapia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
| | - Luiz C Rodrigues Junior
- Laboratorio de Imunovirologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil
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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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Zečević I. Behavioral Management in Encephalitis Rehabilitation: Review of Clinical Research with Clinical Recommendations. JOURNAL OF RATIONAL-EMOTIVE AND COGNITIVE-BEHAVIOR THERAPY 2021. [DOI: 10.1007/s10942-021-00390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hansen MA, Samannodi MS, Hasbun R. Predicting Inpatient Mortality Among Encephalitis Patients: A Novel Admission Risk Score. Open Forum Infect Dis 2020; 7:ofaa471. [PMID: 33204757 PMCID: PMC7651585 DOI: 10.1093/ofid/ofaa471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022] Open
Abstract
Background Identifying underlying commonalities among all-cause encephalitis cases can be extraordinarily useful in predicting meaningful risk factors associated with inpatient mortality. Methods A retrospective cohort of patients with encephalitis was derived from a clinical chart review of adult patients (age ≥18 years) across 16 different hospitals in Houston, Texas, between January 2005 and July 2015. Clinical features at admission were assessed for their correlation with inpatient mortality and used to derive a final risk score prediction tool. Results The study included a total of 273 adult patients with all-cause encephalitis, 27 (9.9%) of whom died during hospitalization. A limited number of clinical features were substantially different between patients who survived and those who died (Charlson score, Glasgow coma scale [GCS], immunosuppression, fever on admission, multiple serologic studies, and abnormal imaging). A final multivariable logistic model was derived with the following risk factors, which were transformed into a scoring system: 1 point was assigned to the presence of a Charlson score >2, thrombocytopenia, or cerebral edema, and 2 points for a GCS value <8. Patients were then classified into different risk groups for inpatient mortality: 0 points (0%), 1 point (7%), 2 points (10.9%), 3 points (36.8%), and ≥4 points (81.8%). Conclusions The risk score developed from this study shows a high predictive value. This can be highly beneficial in alerting care providers to key clinical risk factors associated with in-hospital mortality in adults with encephalitis.
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Affiliation(s)
- Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mohammed S Samannodi
- Department of Medicine, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.,Department of Internal Medicine, UT Health McGovern Medical School, Houston, Texas, USA
| | - Rodrigo Hasbun
- Department of Internal Medicine, UT Health McGovern Medical School, Houston, Texas, USA
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Hansen ABE, Vestergaard HT, Dessau RB, Bodilsen J, Andersen NS, Omland LH, Christiansen CB, Ellermann-Eriksen S, Nielsen L, Benfield T, Sørensen HT, Andersen CØ, Lebech AM, Obel N. Long-Term Survival, Morbidity, Social Functioning and Risk of Disability in Patients with a Herpes Simplex Virus Type 1 or Type 2 Central Nervous System Infection, Denmark, 2000-2016. Clin Epidemiol 2020; 12:745-755. [PMID: 32765109 PMCID: PMC7371560 DOI: 10.2147/clep.s256838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background The long-term prognosis following herpes simplex virus (HSV) central nervous system (CNS) infection is still debated. Patients and Methods We examined outcomes in all Danish residents who, during 2000–2016, tested PCR positive for HSV-1 (n=208) or HSV-2 (n=283) in the cerebrospinal fluid, compared to comparison cohorts from the general population (n=2080 and n=2830). Results One-year mortality was increased among HSV-1 patients (difference 19.3%; 95% CI: 13.6% to 25.0%) and HSV-2 patients (difference 5.3%; 95% CI: 2.5% to 8.1%), but thereafter mortality was not increased. After exclusion of persons diagnosed with cancer prior to study inclusion, one-year mortality difference for HSV-2 patients was 1.7% (−0.1% to 3.5%). After five years, HSV-1 patients had lower employment (difference −19.8%; 95% CI: −34.7% to −4.8%) and higher disability pension rates (difference 22.2%; 95% CI: 8.4% to 36.0%) than the comparison cohort, but similar number of inpatient days, outpatient visits, and sick leave. HSV-2 patients had employment and disability pension rates comparable to the comparison cohort, but more inpatient days (difference 1.5/year; 95% CI: −0.2 to 3.2), outpatient visits (difference 1.3/year; 95% CI: 0.3 to 3.2), and sick leave days (difference 9.1/year; 95% CI: 7.9 to 10.4). Conclusion HSV-1 and HSV-2 CNS infections differ substantially with respect to prognosis. HSV-1 CNS infection is followed by increased short-term mortality and long-term risk of disability. HSV-2 CNS infection has no substantial impact on mortality or working capability but is associated with increased morbidity.
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Affiliation(s)
- Ann-Brit E Hansen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne T Vestergaard
- Department of Virus & Microbiological Special Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Ram B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Bodilsen
- Departments of Infectious Diseases and Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna S Andersen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lars H Omland
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus B Christiansen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Lene Nielsen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Amager Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Ø Andersen
- Department of Clinical Microbiology, Amager Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Anne-Mette Lebech
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Blum RA, Tomlinson AR, Jetté N, Kwon CS, Easton A, Yeshokumar AK. Assessment of long-term psychosocial outcomes in anti-NMDA receptor encephalitis. Epilepsy Behav 2020; 108:107088. [PMID: 32375094 DOI: 10.1016/j.yebeh.2020.107088] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to assess long-term psychosocial outcomes of anti-N-methyl-d-aspartate (NMDA) receptor encephalitis (anti-NMDARE). METHODS Adolescents and adults with self-reported anti-NMDARE were invited to complete an online survey distributed by relevant patient organizations. Demographic and clinical information was collected, including the diagnoses initially given for anti-NMDARE symptoms and posthospital care received. Patient-Reported Outcomes Measurement Information System (PROMIS) Psychosocial Impact Illness - Negative short form (Negative PSII) was administered to assess psychosocial outcome of anti-NMDARE. Associations between clinical factors and psychosocial outcomes were evaluated. RESULTS Sixty-one individuals with anti-NMDARE age 15 years and above participated. Mean age was 33.7 years (standard deviation [SD]: 12.8), and participants were predominantly female (90.2%, n = 55). Mean T-score on PROMIS Negative PSII was 60.7, >1 SD higher (worse psychosocial function) than that of the provided normalized sample enriched for chronic illness (50, SD: 10). Initial misdiagnosis of anti-NMDARE symptoms was associated with decreased odds (odds ratio [OR]: 0.11, p < 0.05), and follow-up with a psychiatrist after hospitalization with increased odds (OR: 8.46, p < 0.05), of return to work/school after illness. Younger age of symptom onset and presence of ongoing neuropsychiatric issues were predictive of worse Negative PSII scores (p < 0.05). CONCLUSION Individuals with anti-NMDARE demonstrate poor psychosocial outcomes, yet there are no current standards for long-term assessment or management of such symptoms in this population. These findings highlight the need for use of more comprehensive outcome measures that include assessment of psychosocial function and the importance of developing interventions that address this domain for individuals with anti-NMDARE.
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Affiliation(s)
- Raia A Blum
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Amanda R Tomlinson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
| | - Ava Easton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool L69 7BE, UK; The Encephalitis Society, 32 Castlegate, Malton YO17 7DT, North Yorkshire, UK.
| | - Anusha K Yeshokumar
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA; Autoimmune Encephalitis Alliance, 920 Urban Avenue, Durham, NC 27701, USA.
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11
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Affiliation(s)
- Marta Frackowiak
- Junior Doctor, Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool
| | - Ava Easton
- Chief Executive, Encephalitis Society, Malton, North Yorkshire YO17 7DT
| | - Benedict D Michael
- Doctor, Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool
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Lemon J, Cooper J, Defres S, Easton A, Sadarangani M, Griffiths MJ, Pollard AJ, Solomon T, Kneen R. Understanding parental perspectives on outcomes following paediatric encephalitis: A qualitative study. PLoS One 2019; 14:e0220042. [PMID: 31525232 PMCID: PMC6746349 DOI: 10.1371/journal.pone.0220042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 07/08/2019] [Indexed: 11/18/2022] Open
Abstract
Background Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis. Methods Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically. Results Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness. Conclusion Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery.
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Affiliation(s)
- Jennifer Lemon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Jessie Cooper
- School of Health Sciences, Division of Health Services Research and Management, City University of London, London, United Kingdom
| | - Sylviane Defres
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Tropical Infectious Diseases Unit, Royal Liverpool University and Broadgreen NHS Trust, Liverpool, United Kingdom
| | - Ava Easton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Encephalitis Society, Malton, United Kingdom
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children’s Hospital Research Institute, Vancouver, Canada
- Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Michael J. Griffiths
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
| | - Rachel Kneen
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
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Harder JA, Mariano TY. The importance of comprehensive neuropsychiatric care in the postencephalitic patient. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2018-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Jessica A Harder
- Department of Psychiatry, Brigham & Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Timothy Y Mariano
- Department of Psychiatry, Brigham & Women's Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA, USA
- Butler Hospital, Providence, RI, USA
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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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