Herpes Simplex Type 2 Encephalitis and Methotrexate Medication: A Fortuitous or Causative Association in a Patient with Spondyloarthritis?

Abstract

It is unclear whether immunosuppression is a risk factor for herpes encephalitis. Herein, we describe a rare case of herpes simplex virus type 2 encephalitis in a patient treated with low-dose methotrexate for HLA-B27-associated spondyloarthritis. The patient was successfully treated with acyclovir but presented sequelae of encephalitis. Here we discuss the possible role of low-dose methotrexate therapy as a risk factor of neurological herpes reactivation and severe disease. The host-related and viral risk factors are also addressed.

Herpes simplex virus encephalitis in a patient receiving ustekinumab associated with extensive cerebral oedema and brainshift successfully treated by immunosuppression with dexamethasone

“…Immunocompromise can be caused by treatments used in a wide range of clinical scenarios, such as cancer, transplantation and inflammatory conditions 8 9. There have been many case reports linking specific drugs to cases of HSV encephalitis, particularly methotrexate,5 ciclosporine,10 fingolimod,11 antiTNFα class of drugs,12 temozolomide13 and ipilimumab 14. As these are either singular case reports or case series, we cannot characterise the differences in clinical presentations of HSV encephalitis caused by each drug.…”

“…In this paper, we report the first case of HSV encephalitis in a patient receiving ustekinumab to the authors’ knowledge. Broad-spectrum immune-suppressive agents, including steroids and methotrexate, have been reported to reduce cerebral oedema in HSV encephalitis 4 5. However, this case demonstrates that new, more targeted, immunomodulatory therapies can be associated with marked cerebral oedema and brainshift, which was successfully treated by immunosuppression with dexamethasone 4 5…”