HSV-2 meningoencephalitis in an immunocompetent young man: what is the pathogenesis and what is the treatment?

Fernandez-Gerlinger, Marie-Paule; Greffe, S.; Meffre, A.; Grenet, J.; Au, Siu-Ming; Bojanova, Magdalena; Rouveix, É.; Rozenberg, Flore

doi:10.1016/j.jcv.2015.05.027

Cited by 4 publications

(4 citation statements)

References 27 publications

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“…As a result, less exposure to HSV in juveniles led to a significantly lower risk. This was consistent with other studies which have shown that a history mucocutaneous infection, including skin involvement, gingivostomatitis and genitourinary involvement,38–40 might be diagnostic clues in susceptible circumstances,38 39 41 such as steroid use in our study. The clinical implication of this study is that HSV should be considered a possible differential diagnosis, and early treatment should be applied to prevent severe complications in patients with SLE undergoing steroid therapy.…”

Section: Discussionsupporting

confidence: 93%

Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan

Lai

Wang

et al. 2019

Ann Rheum Dis

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ObjectivePatients with systemic lupus erythematosus (SLE) are susceptible to herpes simplex virus (HSV) infection, which occasionally leads to severe complications including meningoencephalitis and keratitis. However, few attempts to analyse the associated incidence and risk factors have been made.MethodsWe enrolled patients with SLE recorded between 1997 and 2012 and compared the incidence rate (IR) of severe HSV infection, including meningoencephalitis, septicaemia, ocular and visceral involvement, and other specific complications demanding hospitalisation, with that of a non-SLE cohort. A Cox multivariate proportional hazards model was applied to analyse the risk factors of severe HSV infection in patients with SLE.ResultsA total of 122 520 subjects (24 504 patients with SLE and 98 016 age-matched and sex-matched non-SLE controls) were included, and a higher IR of severe HSV infection was revealed in the SLE group (IR ratio=3.93, p<0.001). In patients with SLE, previous oral and genital infection (HR=2.29, p=0.049), intravenous steroid pulse therapy (HR=5.32, p<0.001) and daily oral dose of over 7.5 mg of prednisolone (HR=1.59, p=0.024) were independent risk factors for severe HSV infection, whereas age of ≤18 (HR=0.45, p=0.029) was a protective factor.ConclusionsPatients with SLE are at higher risk of severe HSV infection, and related risk factors include being older than 18 years, having a history of HSV mucocutaneous infection, recent receipt of steroid pulse therapy and a daily oral dose of steroid over 7.5 mg prednisolone.

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Section: Discussionsupporting

confidence: 93%

Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan

Lai

Wang

et al. 2019

Ann Rheum Dis

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“…However, to our knowledge, no study has yet described an association between the HSV-2 load in CSF and the clinical feature of the neurological HSV-2 infection (HSV-2 meningitis or encephalitis). A number of studies suggested that HSV-2 infection may cause fewer neurological sequelae than HSE caused by HSV-1 [2,21], but several reports also described HSV-2 encephalitis with severe outcome [3,22]. In a large multinational retrospective study including 501 PCR-proven herpetic meningoencephalitis cases diagnosed between 2000 and 2013, the mortality rate was 10% and nearly 43% of the patients survived with severe sequela(e), but the difference in outcome between HSV-1 and HSV-2 was not studied [17].…”

Section: Discussionmentioning

confidence: 99%

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

Lupo¹,

Santos²,

Germi³

et al. 2016

Antiviral Therapy

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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.

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“…1 MRI can be nonspecific, there may be a predilection for the brainstem, and nerve root enhancement can occur. 2 This patient had no prior diagnosis of genital herpes. In searching for an underlying immunodeficiency, HIV antibodies and PCR were negative, and CD4 count was normal, but we uncovered low natural killer (NK) cell levels (47 cells/mL, reference range 59-401 cells/mL) at the time of her acute illness that later became normal.…”

Section: Practical Implicationsmentioning

confidence: 96%

Disseminated HSV-2 presenting with relapsing encephalomyelitis

et al. 2016

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A previously healthy 39-year-old woman presented with 3 weeks of progressive leg numbness. Examination showed mild bilateral iliopsoas weakness and patchy leg numbness. She was admitted, and spinal MRI revealed T2 enhancing thoracic lesions, nonenhancing cervical cord lesions (figure, A), and subtle pial and cauda equina enhancement (figure, B). Brain MRI revealed multiple periventricular T2 hyperintensities (figure, C). Since the diagnosis of multiple sclerosis (MS) was considered likely, lumbar puncture (LP) was deferred and she received 5 days of IV methylprednisolone. One week later, she developed increasing right-sided hearing loss and vertigo with right cochlear enhancement (figure, D). Two weeks later, a morbilliform and vesicular flank and trunk rash appeared (figure, E and F). She was readmitted and treated with IV acyclovir for presumed disseminated varicella zoster virus (VZV). LP revealed a lymphocytic pleocytosis (90 leukocytes, 100% lymphocytes) and elevated protein (150 mg/dL). Oligoclonal bands were positive, and neuromyelitis optica and human T-cell lymphotropic virus-1 antibodies were negative. A PCR encephalitis panel was positive for herpes simplex virus (HSV)-2 and negative for VZV and HSV-1. Skin biopsy viral culture and PCR were positive for HSV. Three weeks after rash onset, the patient developed worsening leg numbness, received 5 more days of IV methylprednisolone, and soon after developed severe ataxia and weakness. Repeat MRI revealed new pontine lesions atypical for MS, punctate lesions following a vascular distribution, and new enhancing spinal cord lesions ( figure, G and H). Repeat LP revealed a decreasing leukocyte count (17 leukocytes) and rising protein (298 mg/dL). CSF HSV-2 PCR was now negative, yet quantitative ELISA revealed positive HSV-2 immunoglobulin G (IgG) (8.83 antibody index [AI]) and negative HSV-1 IgG (0.3 [reference range 0.9 AI]). CSF HSV-1 and HSV-2 immunoglobulin M (IgM) (1.15) and IgG titers were elevated (27.93 [reference range 0.9 AI]). A unifying diagnosis of HSV-2 encephalomyelitis was made. The patient was treated with plasmapheresis, followed by IV immunoglobulin (IVIG), concurrently with 6 weeks of IV acyclovir. A follow-up LP 3 weeks after treatment initiation demonstrated decreasing HSV IgM (0.22 AI) and IgG (7.96 AI) titers, pleocytosis (6 leukocytes), and protein (111 mg/dL), consistent with declining inflammation. Monthly follow-up imaging showed interval resolution of spinal enhancement and no new lesions, commensurate with resolving sensory symptoms and ataxia.

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HSV-2 meningoencephalitis in an immunocompetent young man: what is the pathogenesis and what is the treatment?

Cited by 4 publications

References 27 publications

Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan

Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan

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

Disseminated HSV-2 presenting with relapsing encephalomyelitis

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