Herpes simplex Virus Myelitis: Clinical Manifestations and Diagnosis by the Polymerase Chain Reaction Method

Abstract

Herpes simplex virus (HSV) myelitis has previously been reported to be a form of acute ascending necrotizing myelitis caused by HSV type 2 (HSV-2). We studied neurological symptoms, clinical course, magnetic resonance imaging (MRI) findings, and diagnosis by polymerase chain reaction (PCR) methods in 9 patients with HSV myelitis. In 6 cases, disease onset was marked by sensorimotor disturbances of lower extremities and urinary disturbances, with the transverse myelopathy gradually ascending to the cervicothoracic spinal cord level. The other 3 cases showed transverse myelopathy without an ascending pattern. Six cases showed acute progression, while 3 cases showed a subacute course. There were 2 cases with recurrent episodes. Three patients recovered, however, in the remaining 6 patients severe sequelae such as paraplegia persisted despite antiviral therapy. MRI showed a hyperintense lesion on T2-weighted images. Gadolinium enhancement was observed in 2 cases, and 1 case showed a hyperintense lesion both on T1- and on T2-weighted images, suggesting hemorrhagic necrosis. HSV-2 was detected by PCR techniques in all 6 cases with an ascending pattern. HSV-1 DNA was detected in 2 and HSV-2 DNA in 1 of the 3 cases with a nonascending pattern. Our findings demonstrate diverse clinical manifestations of HSV myelitis.

HSV2 reactivation and myelitis following influenza vaccination

“…One case series reported 7 patients who developed myelitis with paraplegia or tetraplegia following acute HSV-2 infection; all were treated with antiviral therapy but only 2 made a substantial recovery. 9 Antiviral drugs are the mainstay of treating acute infections HSV-2. 10 Double-blind studies have indicated that use of antiviral drugs such as acyclovir, valacyclovir, and famciclovir moderately reduce risk of HSV-2 recurrences over a 2 to 12 month period by 43 to 59% (results statistically significant).…”

Subacute progressive ascending myelopathy following spinal cord injury: MRI appearances and clinical presentation

“…There is some similarity in both the cord appearance and delayed clinical deterioration with other insults to the spinal cord. Patients have developed similar clinical and imaging features following episodes of virally infective myelitis 14 or electric shocks. 15 …”

Herpes Simplex Myelitis: Differences in Clinical Manifestations Between Herpes Simplex Virus Type 1 and Type 2

“…As MRI findings, spinal lesions of HSM are generally either hypointense or isointense on T1-weighted images and hyperintense on T2-weighted images similar to images obteined in HSV encephalitis (Ellie et al, 1994;Petereit et al, 1996;Nakajima et al, 1998;Kuker, et al, 1999;Galanakis et al, 2001;Gobbi et al, 2001;Azuma et al, 2001) (Fig. 1).…”

“…In the past, an antiviral agent and a steroidal agent were concurrently administered in many patients. Of the 9 patients in the above mentioned study, a steroidal agent was administered concurrently: methylprednisolone pulse therapy in 4 patients, betamethasone in 2 patients and predonine in 1 patient (Nakajima et al, 1998). Regarding the use of steroids, while s t e r o i d s w e r e u s e d a f t e r c o n f i r m i n g H S M i n s o m e p a t i e n t s , t h e y w e r e a l s o u s e d i n combination with antiviral agents because of suspected demyelinating disease, such as ADEM or multiple sclerosis; autoimmune/inflammatory diseases, such as, vasculitis; or cryptogenic transverse myelopathy.…”