Neurologic outcome of VZV encephalitis one year after ICU admission: a multicenter cohort study

Abstract

Background Varicella-zoster virus (VZV) is one of the main viruses responsible of acute encephalitis. However, data on the prognosis and neurologic outcome of critically ill patients with VZV encephalitis are limited. We aimed to describe the clinical features of VZV encephalitis in the ICU and to identify factors associated with a favorable neurologic outcome. We performed a multicenter cohort study of patients with VZV encephalitis admitted in 18 ICUs in France between 2000 and 2017. Factors associated with a favorable neurologic outcome, defined by a modified Rankin Score (mRS) of 0–2 1 year after ICU admission, were identified by multivariable regression analysis. Results Fifty-five patients (29 (53%) men, median age 53 (interquartile range 36–66)) were included, of whom 43 (78%) were immunocompromised. ICU admission occurred 1 (0–3) day after the onset of neurological symptoms. Median Glasgow Coma Score at ICU admission was 12 (7–14). Cerebrospinal fluid examination displayed a median leukocyte count of 68 (13–129)/mm3, and a median protein level of 1.37 (0.77–3.67) g/L. CT scan and MRI revealed brain lesions in 30% and 66% of the cases, respectively. Invasive mechanical ventilation was implemented in 46 (84%) patients for a median duration of 13 (3–30) days. Fourteen (25%) patients died in the ICU. One year after ICU admission, 20 (36%) patients had a favorable neurologic outcome (mRS 0–2), 12 (22%) had significant disability (mRS 3–5), and 18 (33%) were deceased (lost to follow-up n = 5, 9%). On multivariable analysis, age (OR 0.92 per year, (0.88–0.97), p = 0.01), and invasive mechanical ventilation (OR 0.09 CI 95% (0.01–0.84), p = 0.03) reduced the likelihood of favorable neurologic outcome. Conclusion One in every three critically ill patients with VZV encephalitis had a favorable neurologic outcome 1 year after ICU admission. Older age and invasive mechanical ventilation were associated with a higher risk of disability and death.

Can we forecast poor outcome in herpes simplex and varicella zoster encephalitis? A narrative review

“…Encephalitis and meningitis due to VZV infection has a mortality rate of 0–15%, with fatal cases more likely during an encephalitic disease course ( 11 , 34 , 43 , 53 , 54 , 57 , 59 , 62 – 64 , 67 – 70 ). Only two studies reported mortality rates as high as 33% ( 72 ) and 36% ( 70 ). The first of these included only patients with severe encephalitis requiring intensive care (median GCS at admission 12, and mechanical ventilation in 84%) ( 72 ).…”

Varicella-Zoster Virus: A Case of Encephalitis

“…These changes are usually preceded by a vesicular skin rash; however, clinical manifestations may be atypical in immunosuppressed individuals, and skin lesions may be absent, masking the diagnosis of VZV infection in these patients [ 6 ]. As is the case with the patient presented, despite being rarer, they have become more frequent due to the improvement and advancement of diagnostic methods, such as the polymerase chain reaction (PCR), which has significantly contributed to better identification in the CSF of many neurotropic viruses capable of causing infectious encephalitis [ 7 ].…”

“…Although neuroimaging is an important component in the investigation of acute encephalitis, CT often does not demonstrate any alteration, with MRI being the best method for evaluating the brainstem, deep brain structures, and cerebellum and identifying signs of vasculitis. The most common findings are edematous changes with hyperintense areas on the T2 sequence, mainly in the temporal and inferior frontal lobes, with cerebral vasculitis being a frequent complication of VZV encephalitis and stenoses of the cerebral arteries often associated with ischemic lesions of the gray-white matter interface, which is associated with a higher risk of long-term comorbidities [ 5 , 7 ]. In this case, the brain MRI findings are atypical due to the absence of acute ischemic lesions with diffusion restriction, associated with damage to the vascular endothelium.…”

Severe meningoencephalitis: epidemiology and outcomes

“…A multicenter retrospective cohort study found that 80% of patients with VZV encephalitis had underlying immunosuppression [30 ▪ ]. Abnormal brain MRI findings were observed in two-thirds of patients, of whom 15% had signs of cerebral vasculitis.…”

“…ICU mortality reached 25%, and a favorable neurologic outcome 1 year after ICU discharge was reported in only 36% of cases. Older age and the need for invasive mechanical ventilation were associated with an increased risk of poor outcome [30 ▪ ]. In contrast, early intravenous acyclovir has been associated with a better prognosis [31].…”