Severe cytomegalovirus encephalitis in an immunocompetent healthy young woman: A case report

Clinical presentation of cytomegalovirus meningoencephalitis: a retrospective study of 12 adult patients with a variety of immunocompromised conditions

BACKGROUND

Human Cytomegalovirus (HCMV) is a crucial pathogen in immunocompromised individuals, causing infections such as pneumonitis, colitis, and retinitis. However, research on HCMV infections of the central nervous system (CNS) is limited.

OBJECTIVE

This retrospective cohort study aimed to investigate the clinical manifestations, underlying conditions, laboratory findings, imaging findings, treatments, and outcomes of adult patients diagnosed with HCMV meningitis or encephalitis at a single medical center in East Asia over a 6-year period.

METHODS

The study included patients who had positive results in quantitative polymerase chain reaction (PCR) tests of their cerebrospinal fluid (CSF) for HCMV at any time between January 2017 and December 2022. Clinical characteristics, laboratory findings, imaging findings, treatment approaches, and outcomes were reviewed and analyzed from electronic medical records.

RESULTS

The cohort comprised 12 patients with a median age of 61 years (range, 43-84 years). Stupor and generalized seizures were the most common neurological presentations. Brain imaging findings in half of the patients revealed nonspecific abnormalities, such as atrophy. CSF protein levels were elevated, with a median of 74.5 mg/dL. CSF pleocytosis was observed in three patients (25%) and was predominantly lymphocytic. The in-hospital mortality rate was 75% (9 out of 12 patients).

CONCLUSIONS

Although rare, HCMV CNS infections are associated with a high mortality rate. CSF pleocytosis is uncommon in such cases, potentially contributing to clinical misdiagnosis or underestimation. HCMV meningoencephalitis should be considered in immunocompromised patients who present with unexplained seizures or altered consciousness.

Clinic-radiological classification of herpesviral encephalitis in humans (systematic review)

The development of a comprehensive classification for herpesvirus encephalitis remains an urgent task. Distinct clinic-radiological forms of herpesvirus cerebral lesions have been characterized, including findings from histopathological studies. Differences among these forms have been demonstrated concerning key clinical and paraclinical parameters. The presented classification identifies several distinct forms of herpesvirus encephalitis: temporal, brainstem, limbic, diencephalic encephalitis, rhombencephalitis, leukoencephalitis, ventriculoencephalitis, diffuse glial micronodular encephalitis, subcortical and cortical encephalitis, cerebellitis, neonatal encephalitis. Additionally, the concepts of combined, coexisting and multimodal lesions are introduced to describe complex forms of herpesvirus neuroinfections. The use of the term "specific spectrum of herpesvirus cerebral lesions" is supported. Both the phenomena of specificity and universality are considered. Fundamental differences between the forms of herpesvirus encephalitis are highlighted with respect to their prevalence within the population, etiological factors, clinical manifestations, typical complications, recovery completeness, mortality rates, immune status. The distinctive diagnostic and therapeutic approaches required for each form of herpesvirus encephalitis are emphasized. The integration of this classification into clinical practice has the potential to optimize medical care for patients with herpesvirus encephalitis, enabling not only etiologically-oriented but also form-specific approaches to treatment.

Meningoencephalitis in a background of inherited chromosomic integration of HHV-6 and CMV infection in an immunocompetent adult, which one is the culprit?

HHV-6 meningoencephalitis has been reported in immunocompromised individuals but is very uncommon in immunocompetent individuals. However, HHV-6 is the second most frequently detected virus in multiplex PCR tests. As HHV-6 DNA integrates in the telomeric region of host chromosomes after primary infection and can be passed onto offspring, 1 % of the population carries an inherited HHV-6 genome (iciHHV-6). This makes it difficult to interpret a positive multiplex PCR test for HHV-6. Here, we describe a 39-year-old female patient with an unremarkable medical history and who was hospitalized for meningoencephalitis. The brain imaging findings were normal. The positive multiplex PCR test for HHV-6 was confirmed by qualitative and quantitative HHV-6 PCR tests, the viral load was higher in blood than in CSF. The presence of circulating anti-CMV IgM and IgG in a serologic test and the absence of other pathogens argued in favor of a primary CMV infection. However CMV PCR was negative. The chromosomal integration of HHV-6 was subsequently confirmed by the results of a hair bulb analysis. Our primary hypothesis was CMV meningoencephalitis in a context of inherited chromosomic integration of HHV-6 without be able to confirm the possible role of HHV-6 (reactivation or bystander) in this situation. A commercially available assay able to certify HHV-6 replication in a context of iciHHV-6 would have been useful to conclude.

Guillain-Barré Syndrome and Encephalitis Following a Cytomegalovirus Infection in an Immunocompetent Adult: A Case Report

BACKGROUND Cytomegalovirus (CMV) is a common herpesvirus that often causes asymptomatic or mild infections. In immunocompromised patients, CMV can lead to severe complications, including Guillain-Barre syndrome (GBS) and encephalitis. While these conditions have been described in the immunocompetent population, simultaneous presentation of CMV-associated GBS and encephalitis in such individuals has not been previously reported. CASE REPORT We present a case of a 58-year-old woman with poorly controlled diabetes who developed concurrent GBS and encephalitis following a CMV infection. The patient experienced bilateral ascending paraparesis 1 week after self-limited gastrointestinal symptoms. Despite initial treatment with plasma exchange therapy, her condition deteriorated with altered mental status and generalized tonic-clonic seizures, necessitating orotracheal intubation. Laboratory analysis revealed the presence of CMV in her cerebrospinal fluid. After treatment with further sessions of plasma exchange therapy and ganciclovir, her muscular strength in the extremities improved. However, she developed acute lung edema and failed extubation, leading to cardiorespiratory arrest with neurological sequelae. Palliative care was institutionalized, and she died 2 weeks later due to pneumonia. CONCLUSIONS This case highlights an unusual clinical presentation of overlapping CMV-associated GBS and encephalitis in an immunocompetent individual, with diabetes as the only identified risk factor. It underscores the importance of considering CMV as a potential etiological factor in such complex cases and the need for prompt diagnosis to improve patient outcomes. Further research is warranted to explore the underlying mechanisms and implications of this rare overlapping neurological manifestation.

Host-microbe interactions at the blood-brain barrier through the lens of induced pluripotent stem cell-derived brain-like endothelial cells

Microbe-induced meningoencephalitis/meningitis is a life-threatening infection of the central nervous system (CNS) that occurs when pathogens are able to cross the blood-brain barrier (BBB) and gain access to the CNS. The BBB consists of highly specialized brain endothelial cells that exhibit specific properties to allow tight regulation of CNS homeostasis and prevent pathogen crossing. However, during meningoencephalitis/meningitis, the BBB fails to protect the CNS. Modeling the BBB remains a challenge due to the specialized characteristics of these cells. In this review, we cover the induced pluripotent stem cell-derived, brain-like endothelial cell model during host-pathogen interaction, highlighting the strengths and recent work on various pathogens known to interact with the BBB. As stem cell technologies are becoming more prominent, the stem cell-derived, brain-like endothelial cell model has been able to reveal new insights in vitro, which remain challenging with other in vitro cell-based models consisting of primary human brain endothelial cells and immortalized human brain endothelial cell lines.

Cytomegalovirus colitis in immunocompetent hosts: A case report and literature review

Key Clinical Message

Rectal bleeding can manifest cytomegalovirus (CMV) colitis even in immunocompetent patients, which can be cured with ganciclovir treatment.

Abstract

Cytomegalovirus (CMV) is an opportunistic virus widely affecting immunocompromised patients. Different manifestations varied from asymptomatic in immunocompetent individuals to end organ involvement, such as colitis in those with immunodeficiency. Despite the rarity of CMV colitis in immunocompetent hosts, we should consider it when the other conditions have been excluded. In this article, we have described a case of CMV colitis in an immunocompetent host and have performed a literature review on this entity. An immunocompetent 70-year-old female was admitted to the hospital with recurrent rectal bleeding. After various evaluations including laboratory analysis, stool examination, and colonoscopy, we have detected superficial lesions. Pathology and polymerase chain reaction reports favored CMV involvement. Her condition continues to improve after intravenous ganciclovir infusion. Rectal bleeding can manifest CMV colitis even in immunocompetent patients, which can be cured with ganciclovir treatment.

Identification of Small Molecule Inhibitors of Human Cytomegalovirus pUL89 Endonuclease Using Integrated Computational Approaches

Replication of Human Cytomegalovirus (HCMV) requires the presence of a metal-dependent endonuclease at the C-terminus of pUL89, in order to properly pack and cleave the viral genome. Therefore, pUL89 is an attractive target to design anti-CMV intervention. Herein, we used integrated structure-based and ligand-based virtual screening approaches in combination with MD simulation for the identification of potential metal binding small molecule antagonist of pUL89. In this regard, the essential chemical features needed for the inhibition of pUL89 endonuclease domain were defined and used as a 3D query to search chemical compounds from ZINC and ChEMBL database. Thereafter, the molecular docking and ligand-based shape screening were used to narrow down the compounds based on previously identified pUL89 antagonists. The selected virtual hits were further subjected to MD simulation to determine the intrinsic and ligand-induced flexibility of pUL89. The predicted binding modes showed that the compounds reside well in the binding site of endonuclease domain by chelating with the metal ions and crucial residues. Taken in concert, the in silico investigation led to the identification of potential pUL89 antagonists. This study provided promising starting point for further in vitro and in vivo studies.