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Gabrielli L, Banchini I, Petrisli E, Piccirilli G, Venturoli S, Pavoni M, Cantiani A, Lanna F, Campoli C, Montironi M, Giannella M, Lazzarotto T. Mollaret's Meningitis due to Herpes Simplex Virus 2: A Case Report and Review of the Literature. Microorganisms 2024; 12:1363. [PMID: 39065131 PMCID: PMC11278522 DOI: 10.3390/microorganisms12071363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Mollaret's meningitis is a rare neurological disorder characterized by recurrent episodes of aseptic lymphocytic meningitis, often associated with herpes simplex virus 2 (HSV-2) infection. We report the case of a 39 y.o. Italian woman who experienced four episodes of aseptic lymphocytic meningitis between 2004 and 2023, diagnosed as Mollaret's meningitis. In each episode, the patient presented with fever, severe headache and photophobia. In two episodes cutaneous vesicles in the left gluteal area preceding meningitis symptoms were also reported. A diagnostic evaluation included a physical-chemical analysis and a real-time PCR of the cerebrospinal fluid (CSF). The CSF presented pleocytosis with lymphocytic predominance and a positive HSV-2 load, with a peak of 1234 copies/mL. The patient was treated successfully with acyclovir, and the symptoms resolved without neurological sequelae. This case highlights the importance of comprehensive diagnostic testing and vigilant monitoring to manage Mollaret's syndrome effectively.
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Affiliation(s)
- Liliana Gabrielli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.G.)
| | - Isabella Banchini
- Department of Medical and Surgical Sciences, Section of Microbiology, University of Bologna, 40138 Bologna, Italy
| | - Evangelia Petrisli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.G.)
| | - Giulia Piccirilli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.G.)
| | - Simona Venturoli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.G.)
| | - Matteo Pavoni
- Department of Medical and Surgical Sciences, Section of Microbiology, University of Bologna, 40138 Bologna, Italy
| | - Alessia Cantiani
- Department of Medical and Surgical Sciences, Section of Microbiology, University of Bologna, 40138 Bologna, Italy
| | - Federica Lanna
- Department of Medical and Surgical Sciences, Section of Microbiology, University of Bologna, 40138 Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Matteo Montironi
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Infectious Diseases Section, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.G.)
- Department of Medical and Surgical Sciences, Section of Microbiology, University of Bologna, 40138 Bologna, Italy
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Ferrara JM, Litchmore C, Shah S, Myers J, Ali K. Elsberg Syndrome With Albuminocytologic Dissociation - A Guillain-Barré Syndrome Mimic or Guillain-Barré Syndrome Variant? Neurohospitalist 2024; 14:322-326. [PMID: 38895011 PMCID: PMC11181979 DOI: 10.1177/19418744241233621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Introduction Elsberg Syndrome is a presumed infectious lumbosacral radiculitis, with or without accompanying lumbar myelitis, that is often attributed to herpes simplex virus type 2 (HSV-2). Case A 58-year-old man presented with lower extremity anesthesia, ataxic gait, radiological evidence of radiculitis, and CSF albuminocytologic dissociation. Polymerase chain reaction testing of CSF confirmed HSV-2 infection. Conclusion A variety of presentations are reported within the scope of Elsberg Syndrome, potentially with distinct disease mechanisms. Delayed onset of neurological symptoms after resolution of rash and absence of pleocytosis raises the possibility that some patients meeting criteria for Elsberg Syndrome have a post-infectious immune-mediated neuropathy. We advise a lower threshold for PCR testing of herpes viruses in patients with acute neuropathy and albuminocytologic dissociation, particularly in cases with early sacral involvement.
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Affiliation(s)
- Joseph M. Ferrara
- Division of Neurology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Courtney Litchmore
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
- Department of Neurology, PRISMA Health, Columbia, SC, USA
| | - Smit Shah
- Department of Neurology, PRISMA Health, Columbia, SC, USA
| | - Jeffery Myers
- Department of Neurology, PRISMA Health, Columbia, SC, USA
| | - Khalil Ali
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
- Department of Neurology, PRISMA Health, Columbia, SC, USA
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Lyons CE, Dixit K. Elsberg Syndrome: A Case Report of a Novel Radiographic Presentation. Neurohospitalist 2024; 14:347-350. [PMID: 38895002 PMCID: PMC11181987 DOI: 10.1177/19418744241241107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Introduction: Elsberg syndrome (ES) presents with bowel and bladder dysfunction, resembling cauda equina syndrome, and is classified as a clinicoradiographic syndrome most commonly associated with HSV-2 reactivation. Most cases reveal smooth and continuous nerve enhancement on imaging. Case Description: We present a unique case of ES that presented as several nodular, ring enhancing soft tissue masses along the cauda equina. An 81-year-old woman presented with several weeks of sacral sensory impairment. MRI of the lumbar spine at presentation showed several nodular, ring enhancing soft tissue masses within the thecal sac along the cauda equina, concerning for leptomeningeal carcinomatosis from an unknown primary source. Cerebrospinal fluid (CSF) analysis was notable for lymphocyte predominant pleocytosis and protein elevation, which was nonspecific but suggestive of leptomeningeal carcinomatosis. CSF rapid meningitis panel was positive for HSV2 which was confirmed on HSV2 PCR. The patient was briefly on on acyclovir and was stopped due to lack of meningioencephalitis symptoms. Malignancy workup with cytological analysis and systemic imaging were negative. Given the absence of malignancy and positive HSV2 PCR, the patient was diagnosed with HSV-2 sacral radiculitis and subsequently treated with a full course of intravenous acyclovir with gradual clinical and radiographic improvement. Discussion: Ring-enhancing lesions along the cauda equina are most suggestive of LC. Our case highlights an as of yet unreported presentation of ES which may be valuable for neurologists to be aware of as to avoid any potential diagnostic dilemma, minimize unnecessary and costly testing, and not delay effective treatment.
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Affiliation(s)
- Clayton E. Lyons
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karan Dixit
- Division of Neuro-Oncology, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Petersen PT, Bodilsen J, Jepsen MPG, Hansen BR, Storgaard M, Larsen L, Helweg‐Larsen J, Wiese L, Lüttichau HR, Andersen CØ, Mogensen TH, Nielsen H, Brandt CT. Benign recurrent lymphocytic meningitis (Mollaret's meningitis) in Denmark: a nationwide cohort study. Eur J Neurol 2024; 31:e16081. [PMID: 37797296 PMCID: PMC11235955 DOI: 10.1111/ene.16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND PURPOSE Data on clinical features and outcomes of benign recurrent lymphocytic meningitis (BRLM) are limited. METHODS This was a nationwide population-based cohort study of all adults hospitalized for BRLM associated with herpes simplex virus type 2 (HSV-2) at the departments of infectious diseases in Denmark from 2015 to 2020. Patients with single-episode HSV-2 meningitis were included for comparison. RESULTS Forty-seven patients with BRLM (mean annual incidence 1.2/1,000,000 adults) and 118 with single-episode HSV-2 meningitis were included. The progression risk from HSV-2 meningitis to BRLM was 22% (95% confidence interval [CI] 15%-30%). The proportion of patients with the triad of headache, neck stiffness and photophobia/hyperacusis was similar between BRLM and single-episode HSV-2 meningitis (16/43 [37%] vs. 46/103 [45%]; p = 0.41), whilst the median cerebrospinal fluid leukocyte count was lower in BRLM (221 cells vs. 398 cells; p = 0.02). Unfavourable functional outcomes (Glasgow Outcome Scale score of 1-4) were less frequent in BRLM at all post-discharge follow-up visits. During the study period, 10 (21%) patients with BRLM were hospitalized for an additional recurrence (annual rate 6%, 95% CI 3%-12%). The hazard ratio for an additional recurrence was 3.93 (95% CI 1.02-15.3) for patients with three or more previous episodes of meningitis. CONCLUSIONS Clinical features of BRLM were similar to those of single-episode HSV-2 meningitis, whilst post-discharge outcomes were more favourable. Patients with three or more previous episodes of meningitis had higher risk of an additional recurrence.
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Affiliation(s)
- Pelle Trier Petersen
- Department of Pulmonary and Infectious DiseasesNordsjællands HospitalHillerødDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Jacob Bodilsen
- Department of Infectious DiseasesAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | | | | | - Merete Storgaard
- Department of Infectious DiseasesAarhus University HospitalAarhusDenmark
| | - Lykke Larsen
- Department of Infectious DiseasesOdense University HospitalOdenseDenmark
| | | | - Lothar Wiese
- Department of MedicineZealand University HospitalRoskildeDenmark
| | | | | | - Trine Hyrup Mogensen
- Department of Infectious DiseasesAarhus University HospitalAarhusDenmark
- Department of BiomedicineAarhus University HospitalAarhusDenmark
| | - Henrik Nielsen
- Department of Infectious DiseasesAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Reyahi A, Studahl M, Skouboe MK, Fruhwürth S, Narita R, Ren F, Bjerhem Viklund M, Iversen MB, Christiansen M, Svensson A, Mogensen TH, Eriksson K, Paludan SR. An IKBKE variant conferring functional cGAS/STING pathway deficiency and susceptibility to recurrent HSV-2 meningitis. JCI Insight 2023; 8:e173066. [PMID: 37937644 PMCID: PMC10721272 DOI: 10.1172/jci.insight.173066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/20/2023] [Indexed: 11/09/2023] Open
Abstract
The mechanisms underlying susceptibility to recurrent herpes simplex virus type 2 (HSV-2) meningitis remain incompletely understood. In a patient experiencing multiple episodes of HSV-2 meningitis, we identified a monoallelic variant in the IKBKE gene, which encodes the IKKε kinase involved in induction of antiviral IFN genes. Patient cells displayed impaired induction of IFN-β1 (IFNB1) expression upon infection with HSV-2 or stimulation with double-stranded DNA (dsDNA) and failed to induce phosphorylation of STING, an activation marker of the DNA-sensing cyclic GMP-AMP synthase/stimulator of IFN genes (cGAS/STING) pathway. The patient allele encoded a truncated IKKε protein with loss of kinase activity and also capable of exerting dominant-negative activity. In stem cell-derived microglia, HSV-2-induced expression of IFNB1 was dependent on cGAS, TANK binding kinase 1 (TBK1), and IKBKE, but not TLR3, and supernatants from HSV-2-treated microglia exerted IKBKE-dependent type I IFN-mediated antiviral activity upon neurons. Reintroducing wild-type IKBKE into patient cells rescued IFNB1 induction following treatment with HSV-2 or dsDNA and restored antiviral activity. Collectively, we identify IKKε to be important for protection against HSV-2 meningitis and suggest a nonredundant role for the cGAS/STING pathway in human antiviral immunity.
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Affiliation(s)
- Azadeh Reyahi
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Marie Studahl
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Stefanie Fruhwürth
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ryo Narita
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Fanghui Ren
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Moa Bjerhem Viklund
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Alexandra Svensson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Trine H. Mogensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Kristina Eriksson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Søren R. Paludan
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Edi VM, Rao P, Igo JO, Odega AS, Soladoye E, Ibeneme CN, Okobi OE. Mollaret's Syndrome: A Case Report. Cureus 2023; 15:e38559. [PMID: 37284381 PMCID: PMC10239340 DOI: 10.7759/cureus.38559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
Abstract
Benign recurrent aseptic meningitis is a rare condition characterized by recurring, self-limited episodes of aseptic meningitis. Meningeal irritation typically occurs first, accompanied by fever and mononuclear cell pleocytosis. The diagnosis is only made after other known causes of lymphocytic meningitis have been excluded. Resolution typically occurs within two to seven days without residual neurological deficit. Aseptic meningitis is most frequently caused by viruses; Mollaret's meningitis has been linked to the herpes simplex virus 2 (HSV 2). It is unclear if prophylactic medication is indicated for these patients. We describe a patient who was experiencing her seventh episode of aseptic meningitis.
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Affiliation(s)
- Vivien M Edi
- Internal Medicine, Wellstar Kennestone Hospital, Marietta, USA
| | - Prasad Rao
- Internal Medicine, Wellstar Kennestone Hospital, Marietta, USA
| | - Joanna O Igo
- Family Medicine, West Ottawa Specialty Care, Ottawa, CAN
| | - Amaka S Odega
- Community and Family Medicine, Windsor University School of Medicine, Cayon, KNA
- Public Health, University of South Wales, Cardiff, GBR
- Family Medicine, Olabisi Onabanjo University, Ago Iwoye, NGA
- Psychiatry, PsycIME, London, CAN
| | | | | | - Okelue E Okobi
- Family Medicine, Medficient Health LLC, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
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7
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Current Infections of the Orofacial Region: Treatment, Diagnosis, and Epidemiology. Life (Basel) 2023; 13:life13020269. [PMID: 36836626 PMCID: PMC9966653 DOI: 10.3390/life13020269] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/07/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Undoubtedly, diagnosing and managing infections is one of the most challenging issues for orofacial clinicians. As a result of the diversity of symptoms, complicated behavior, and sometimes confusing nature of these conditions, it has become increasingly difficult to diagnose and treat them. It also highlights the need to gain a deeper insight into the orofacial microbiome as we try to improve our understanding of it. In addition to changes in patients' lifestyles, such as changes in diet, smoking habits, sexual practices, immunosuppressive conditions, and occupational exposures, there have been changes in patients' lifestyles that complicate the issue. Recent years have seen the development of new infection treatments due to the increased knowledge about the biology and physiology of infections. This review aimed to provide a comprehensive overview of the types of infections in the mouth, including the types that viruses, fungi, or bacteria may cause. It is important to note that we searched the published literature in the Scopus, Medline, Google Scholar, and Cochran databases from 2010 to 2021 using the following keywords: "Orofacial/Oral Infections," "Viral/Fungal/Bacterial Infections", "Oral Microbiota" And "Oral Microflora" without limiting our search to languages and study designs. According to the evidence, the most common infections in the clinic include herpes simplex virus, human papillomavirus, Candida albicans, Aspergillus, Actinomycosis, and Streptococcus mutans. The purpose of this study is to review the new findings on characteristics, epidemiology, risk factors, clinical manifestations, diagnosis, and new treatment for these types of infectious diseases.
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Bodilsen J, Tattevin P, Tong SYC, Naucler P, Nielsen H. Treatment of Herpes Simplex Virus Type 2 Meningitis: A Survey Among Infectious Diseases Specialists in France, Sweden, Australia, and Denmark. Open Forum Infect Dis 2022; 9:ofac644. [PMID: 36570969 PMCID: PMC9772874 DOI: 10.1093/ofid/ofac644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background We aimed to describe attitudes toward treatment of herpes simplex virus type 2 (HSV-2) meningitis and prioritize future trials. Methods This was a self-administered online survey of HSV-2 meningitis treatment among infectious diseases (ID) specialists in France, Sweden, Australia, and Denmark. Results A total of 223 ID specialists (45% female) from France (36%), Denmark (24%), Sweden (21%), and Australia (19%) participated in the survey, primarily from university hospitals (64%). The estimated overall response rate was 11% and ranged from 6% (Australia) to 64% (Denmark). Intravenous (IV) acyclovir followed by oral valacyclovir was the favored treatment in 110 of 179 (61%), whereas monotherapy with either IV acyclovir or oral valacyclovir was used by 35 of 179 (20%) and 34 of 179 (19%), respectively. The median total duration was reported to be 7 days (interquartile range, 7-10 days) regardless of antiviral regimen. Immunocompromise influenced decisions on antiviral treatment in 110 of 189 (58%) of respondents, mainly by prolonged total duration of treatment (36/110 [33%]), prolonged IV administration (31/110 [28%]), and mandatory antiviral treatment (25/110 [23%]). Treatment with acyclovir/valacyclovir versus placebo and comparison of acyclovir versus valacyclovir were assigned the highest prioritization scores for future randomized controlled trials on HSV-2 meningitis. Conclusions Perceptions of indications for as well as type and duration of antiviral treatment varied substantially among ID specialists.
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Affiliation(s)
- Jacob Bodilsen
- Correspondence: Jacob Bodilsen, Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark ()
| | - Pierre Tattevin
- European Society of Clinical Microbiology and Infectious Diseases Study Group for Infectious Diseases of the Brain, Basel, Switzerland,Department of Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France,Réseau National de Recherche Clinique en Infectiologie, Paris, France
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia,Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Pontus Naucler
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden,Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Matthews E, Beckham JD, Piquet AL, Tyler KL, Chauhan L, Pastula DM. Herpesvirus-Associated Encephalitis: an Update. CURRENT TROPICAL MEDICINE REPORTS 2022; 9:92-100. [PMID: 36186545 PMCID: PMC9510386 DOI: 10.1007/s40475-022-00255-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/03/2022]
Abstract
Purpose of Review Recent Findings Summary
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10
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Grinney M, Mohseni MM. Recurrent benign lymphocytic (Mollaret’s) meningitis due to herpes simplex virus type 2. Proc AMIA Symp 2022; 35:820-821. [DOI: 10.1080/08998280.2022.2108991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Michael Grinney
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida
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11
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Krett JD, Beckham JD, Tyler KL, Piquet AL, Chauhan L, Wallace CJ, Pastula DM, Kapadia RK. Neurology of Acute Viral Infections. Neurohospitalist 2022; 12:632-646. [PMID: 36147750 PMCID: PMC9485684 DOI: 10.1177/19418744221104778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
As specialists in acute neurology, neurohospitalists are often called upon to diagnose and manage acute viral infections affecting the nervous system. In this broad review covering the neurology of several acute viral infections, our aim is to provide key diagnostic and therapeutic pearls of practical use to the busy neurohospitalist. We will review acute presentations, diagnosis, and treatment of human herpesviruses, arboviruses, enteroviruses, and some vaccine-preventable viruses. The neurological effects of coronaviruses, including COVID-19, are not covered in this review.
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Affiliation(s)
- Jonathan D Krett
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - J David Beckham
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Departments of Immunology & Microbiology, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Kenneth L Tyler
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Departments of Immunology & Microbiology, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Amanda L Piquet
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
| | - Lakshmi Chauhan
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
| | - Carla J Wallace
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Daniel M Pastula
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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12
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Johnston C. Diagnosis and Management of Genital Herpes: Key Questions and Review of the Evidence for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clin Infect Dis 2022; 74:S134-S143. [PMID: 35416970 DOI: 10.1093/cid/ciab1056] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Genital herpes, caused by herpes simplex virus (HSV) type 1 or type 2, is a prevalent sexually transmitted infection (STI). Given that HSV is an incurable infection, there are important concerns about appropriate use of diagnostic tools, management of infection, prevention of transmission to sexual partners, and appropriate counseling. In preparation for updating the Centers for Disease Control and Prevention (CDC) STI treatment guidelines, key questions for management of genital herpes infection were developed with a panel of experts. To answer these questions, a systematic literature review was performed, with tables of evidence including articles that would change guidance assembled. These data were used to inform recommendations in the 2021 CDC STI treatment guidelines.
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Affiliation(s)
- Christine Johnston
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,University of Washington, Seattle, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Jakobsen A, Skov MT, Larsen L, Petersen PT, Brandt C, Wiese L, Hansen BR, Lüttichau HR, Tetens MM, Helweg-Larsen J, Storgaard M, Nielsen H, Bodilsen J. Herpes simplex virus 2 meningitis in adults: A prospective, nationwide, population-based cohort study. Clin Infect Dis 2022; 75:753-760. [PMID: 34979025 DOI: 10.1093/cid/ciab1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Data on the clinical presentation are scarce and prognostic factors of Herpes simplex virus type 2 (HSV-2) meningitis remain unknown. METHODS Prospective, nationwide, population-based database identifying all adults treated for HSV-2 meningitis at departments of infectious diseases in Denmark from 2015-2020. Unfavorable outcome was defined as Glasgow Outcome Scale (GOS) score of 1-4 and extended GOS score of 1-6. Modified Poisson regression was used to compute relative risks with 95% confidence intervals (RR, 95% CI) for unfavorable outcome. RESULTS HSV-2 meningitis was diagnosed in 205 cases (76% female, median age 35 [IQR 27-49]) yielding an incidence of 0.7/100,000/year. Common symptoms were headache 195/204 (95%), photo/phonophobia 143/188 (76%), and neck stiffness 106/196 (54%). Median time to lumbar puncture was 2.0 hours (IQR 1-4.8) and cerebrospinal fluid (CSF) leukocyte count was 360x10 6/L (IQR 166-670) with a mononuclear predominance of 97% (IQR 91-99). Lumbar puncture was preceded by brain imaging in 61/205 (30%). Acyclovir/valaciclovir was administered in 197/205 (96%) cases for a median of 10 days (IQR 7-14).Unfavorable outcome was observed in 64/205 (31%) at discharge and 19/181 (11%) after six months and was not associated with female sex (RR 1.08, 95% CI 0.65-1.79), age ≥35 years (1.28, 0.83-1.97), immuno-compromise (1.07, 0.57-2.03), or CSF leukocyte count >1,000x10 6/L (0.78, 0.33-1.84). CONCLUSIONS HSV-2 meningitis often presented as meningeal symptoms in younger females. Unfavorable outcome at discharge was common and was not associated with sex, age, immune-compromise, or CSF leukocyte count. Sequelae persisted beyond six months in one tenth of patients.
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Affiliation(s)
- Anna Jakobsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Marie Thaarup Skov
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Lykke Larsen
- Research Unit for Infectious Diseases, Odense University Hospital, Odense, Denmark; University of Southern Denmark, Odense, Denmark
| | - Pelle Trier Petersen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark
| | - Christian Brandt
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,Department of Infectious Diseases, Sjælland University Hospital, Roskilde, Denmark
| | - Lothar Wiese
- Department of Infectious Diseases, Sjælland University Hospital, Roskilde, Denmark
| | | | - Hans Rudolf Lüttichau
- Department of Medicine and Infectious Diseases, Herlev Gentofte Hospital, Herlev Copenhagen, Denmark
| | - Malte Mose Tetens
- Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
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QIU T, DAI X, XIAO H, WANG J, CHEN Y, XU X, HUANG L. A case report of benign recurrent aseptic meningitis and literature review. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.55021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Tao QIU
- Zigong First People’s Hospital, China
| | | | - Hua XIAO
- Zigong First People’s Hospital, China
| | - Juan WANG
- Zigong First People’s Hospital, China
| | | | - Xiaoya XU
- Zigong First People’s Hospital, China
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15
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Péan de Ponfilly G, Chauvin A, Salmona M, Benmansour H, Bercot B, Camelena F, Courbin V, Eyer X, Lecorche E, Mougari F, Munier AL, Revue E, LeGoff J, Cambau E, Jacquier H. Impact of a 24/7 multiplex-PCR on the management of patients with confirmed viral meningitis. J Infect 2021; 83:650-655. [PMID: 34626699 DOI: 10.1016/j.jinf.2021.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/13/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023]
Abstract
Objectives The relevance of syndromic multiplex-PCR for the etiological diagnosis of meningitis or meningoencephalitis is still a matter of debate. Here, we studied the impact of a 24/7 multiplex-PCR on the management of patients consulting in the emergency department for suspicion of community-acquired meningitis. Methods We conducted a single-center retrospective study at the Emergency department of Lariboisière University Hospital (Paris, France) including all patients suspected of meningitis. During period 1 (April 2014-March 2017), the molecular assays used for the detection of infectious agents in the cerebrospinal fluid (CSF) were performed during the daytime. During period 2 (April 2017-March 2019), multiplex-PCR (BioFire® Filmarray® Meningitis/Encephalitis Panel [ME], bioMérieux) was performed 24/7. Results During the periods 1 and 2, 4 100 and 3 574 patients were included and 284 (6.9%) and 308 (8.6%) meningitis were diagnosed, respectively. During the periods 1 and 2, the most common causes of meningitis were enterovirus (23.9% and 29.5%), varicella zoster virus (10.2% and 6.8%) and herpes simplex virus-2 (4.2% and 8.1%). For patients with confirmed viral meningitis, a significant decrease was found between period 1 and period 2, respectively for the rate of hospitalization (73.9% vs 42.0%; p < 0.05), the length of stay (3[2–5] vs 2[1–3] days; p < 0.05), the empirical antiviral (26.1% vs 14.5%) and antibacterial administrations (29.3% vs 14.5%; p < 0.05). Conclusions Multiplex-PCR is an important tool in the diagnosis of infectious meningitis in the emergency department and is relevant in the management of meningitis by screening for patients who do not require hospitalization and antibacterial therapy.
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Affiliation(s)
- Gauthier Péan de Ponfilly
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Laboratoire de Microbiologie Clinique et Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Anthony Chauvin
- Emergency Department, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Maud Salmona
- Unit of Virology and Graft, Infectious Agents Department, Saint Louis-Lariboisiere-Fernand Widal University Hospital, APHP, Paris, France; Université de Paris, Inserm U976, team INSIGHT, Paris F-75010, France
| | - Hanaa Benmansour
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Béatrice Bercot
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université de Paris, IAME UMR 1137 INSERM, Paris F-75018, France
| | - Francois Camelena
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université de Paris, IAME UMR 1137 INSERM, Paris F-75018, France
| | - Virginie Courbin
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Xavier Eyer
- Emergency Department, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Emmanuel Lecorche
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université de Paris, IAME UMR 1137 INSERM, Paris F-75018, France
| | - Faïza Mougari
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Anne-Lise Munier
- Department of Infectious Diseases, Service de Microbiologie, APHP, Saint Louis-Lariboisiere-Fernand Widal University Hospital, APHP, 2 rue Ambroise Paré, Paris 75010, France
| | - Eric Revue
- Emergency Department, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Jérôme LeGoff
- Unit of Virology and Graft, Infectious Agents Department, Saint Louis-Lariboisiere-Fernand Widal University Hospital, APHP, Paris, France; Université de Paris, Inserm U976, team INSIGHT, Paris F-75010, France
| | - Emmanuelle Cambau
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université de Paris, IAME UMR 1137 INSERM, Paris F-75018, France
| | - Hervé Jacquier
- Laboratory of Microbiology, Saint Louis-Lariboisiere-Fernand Widal Hospital Group, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France; Université de Paris, IAME UMR 1137 INSERM, Paris F-75018, France.
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16
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Neuro-Ophthalmic Manifestations of Mollaret Meningitis. J Neuroophthalmol 2021; 41:e407-e409. [PMID: 33417418 DOI: 10.1097/wno.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Mollaret meningitis (MM) refers to benign recurrent aseptic meningitis usually following herpes simplex virus 2 (HSV-2) infection. Neuro-ophthalmic manifestations associated with MM are rarely reported. We present a case of recurrent HSV-2 meningitis with the neuro-ophthalmic presentation of papilledema and sixth nerve palsy. To our knowledge, this is the first such description in the English language ophthalmic literature.
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17
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Extensive Herpes Simplex Virus 2 Myeloradiculitis in an Immunocompetent Host. Can J Neurol Sci 2021; 49:722-724. [PMID: 34321126 DOI: 10.1017/cjn.2021.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 816] [Impact Index Per Article: 272.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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Bodilsen J, Mens H, Midgley S, Brandt CT, Petersen PT, Larsen L, Hansen BR, Lüttichau HR, Helweg-Larsen J, Wiese L, Østergaard C, Storgaard M, Nielsen H. Enterovirus Meningitis in Adults: A Prospective Nationwide Population-Based Cohort Study. Neurology 2021; 97:e454-e463. [PMID: 34088872 DOI: 10.1212/wnl.0000000000012294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that enterovirus meningitis (EM) is a frequent and self-limiting condition, the epidemiology of EM in adults was examined. METHODS Using a prospective, nationwide, population-based database, all adults with EM confirmed by PCR of the CSF from 2015 to 2019 were included. Unfavorable outcome was defined as Glasgow Outcome Scale scores of 1-4 at discharge. Modified Poisson regression was used to compute adjusted relative risks (RRs). RESULTS A total of 419 cases of EM in 418 adults (46% female, median age 31 years [interquartile range (IQR) 27-35]) yielded an incidence of 1.80/100,000/year. Admission diagnoses included CNS infection 247/397 (62%), other neurologic conditions 89/397 (22%), and cerebrovascular diseases 33/397 (8%). Genotype was available for 271 cases, of which echovirus 30 accounted for 155 (57%). Patients presented with headache 412/415 (99%), history of fever 303/372 (81%), photophobia 292/379 (77%), and neck stiffness 159/407 (39%). Fever (≥38.0°C) was observed in 192/399 (48%) at admission. The median CSF leukocyte count was 130 106/L (range 0-2,100) with polymorphonuclear predominance (>50%) in 110/396 (28%). Cranial imaging preceded lumbar puncture in 127/417 (30%) and was associated with non-CNS infection admission diagnoses and delayed lumbar puncture (median 4.8 hours [IQR 3.4-7.9] vs 1.5 [IQR 0.8-2.8], p < 0.001). Unfavorable outcome occurred in 99/419 (24%) at discharge; more often in female patients (RR 2.30 [1.58-3.33]) and less frequent in echovirus 30 (RR 0.67 [0.46-1.00]) in adjusted analyses. Outcome remained unfavorable in 22/379 (6%) after 6 months. CONCLUSIONS EM is common among young, healthy adults. Although the long-term prognosis remains reassuring, a substantial proportion have moderate disability at discharge, especially female patients.
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Affiliation(s)
- Jacob Bodilsen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark.
| | - Helene Mens
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Sofie Midgley
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Christian Thomas Brandt
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Pelle Trier Petersen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Lykke Larsen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Birgitte Rønde Hansen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Hans Rudolf Lüttichau
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Jannik Helweg-Larsen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Lothar Wiese
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Christian Østergaard
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Merete Storgaard
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
| | - Henrik Nielsen
- From the Department of Infectious Diseases (J.B.), Aalborg University Hospital; Department of Pulmonary and Infectious Diseases (H.M., C.T.B., P.T.P.), Nordsjællands Hospital, Hillerød; Department of Infectious Diseases (H.M., J.H.-L.), Rigshospitalet; Virology Surveillance and Research Section (S.M.), Department of Microbiological Diagnostics and Virology, Statens Serum Institut, Copenhagen; Department of Infectious Diseases (L.L.), Odense University Hospital; Department of Infectious Diseases (B.R.H.), Hvidovre University Hospital; Department of Clinical Microbiology (C.Ø.), Copenhagen University Hospital, Amager and Hvidovre; Department of Infectious Diseases (H.R.L.), Copenhagen University Hospital, Herlev and Gentofte,; Department of Medicine (L.W.), Zealand University Hospital, Roskilde; Department of Infectious Diseases (M.S.), Aarhus University Hospital; and Departments of Infectious Diseases (H.N.) and Clinical Medicine (H.N.), Aalborg University, Denmark
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Kohil A, Jemmieh S, Smatti MK, Yassine HM. Viral meningitis: an overview. Arch Virol 2021; 166:335-345. [PMID: 33392820 PMCID: PMC7779091 DOI: 10.1007/s00705-020-04891-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
Meningitis is a serious condition that affects the central nervous system. It is an inflammation of the meninges, which is the membrane that surrounds both the brain and the spinal cord. Meningitis can be caused by bacterial, viral, or fungal infections. Many viruses, such as enteroviruses, herpesviruses, and influenza viruses, can cause this neurological disorder. However, enteroviruses have been found to be the underlying cause of most viral meningitis cases worldwide. With few exceptions, the clinical manifestations and symptoms associated with viral meningitis are similar for the different causative agents, which makes it difficult to diagnose the disease at early stages. The pathogenesis of viral meningitis is not clearly defined, and more studies are needed to improve the health care of patients in terms of early diagnosis and management. This review article discusses the most common causative agents, epidemiology, clinical features, diagnosis, and pathogenesis of viral meningitis.
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Affiliation(s)
- Amira Kohil
- Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Sara Jemmieh
- Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Maria K Smatti
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Hadi M Yassine
- Biomedical Research Center, Qatar University, Doha, Qatar.
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21
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Gadhiya KP, Nookala V. A Rare Case of Mollaret's Meningitis Complicated by Chronic Intractable Migraine and Papilledema: Case Report and Review of Literature. Cureus 2020; 12:e7026. [PMID: 32211261 PMCID: PMC7081958 DOI: 10.7759/cureus.7026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mollaret’s meningitis is characterized by recurrent episodes of aseptic meningitis that last two to seven days and resolve spontaneously without any residual neurological deficit or complication. Viruses are the most common cause of aseptic meningitis and herpes simplex virus (HSV) type 2 has been noted as the most commonly associated virus in Mollaret’s meningitis. We describe a rare case of a female who had four episodes of meningitis in a five-year period associated with chronic intractable migraine and papilledema attributed to Mollaret’s meningitis.
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Affiliation(s)
- Kinjal P Gadhiya
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Vinod Nookala
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
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22
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Abstract
PURPOSE OF REVIEW This article describes the clinical presentation, diagnostic approach (including the use of novel diagnostic platforms), and treatment of select infectious and noninfectious etiologies of chronic meningitis. RECENT FINDINGS Identification of the etiology of chronic meningitis remains challenging, with no cause identified in at least one-third of cases. Often, several serologic, CSF, and neuroimaging studies are indicated, although novel diagnostic platforms including metagenomic deep sequencing may hold promise for identifying organisms. Infectious etiologies are more common in those at risk for disseminated disease, specifically those who are immunocompromised because of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), transplantation, or immunosuppressant medications. An important step in identifying the etiology of chronic meningitis is assembling a multidisciplinary team of individuals, including those with specialized expertise in ophthalmology, dermatology, rheumatology, and infectious diseases, to provide guidance regarding diagnostic procedures. SUMMARY Chronic meningitis is defined as inflammation involving the meninges that lasts at least 4 weeks and is associated with a CSF pleocytosis. Chronic meningitis has numerous possible infectious and noninfectious etiologies, making it challenging to definitively diagnose patients. Therefore, a multifaceted approach that combines history, physical examination, neuroimaging, and laboratory analysis, including novel diagnostic platforms, is needed. This article focuses on key aspects of the evaluation of and approach to patients with chronic meningitis. Specific infectious etiologies and differential diagnoses of subacute and chronic meningitis, including noninfectious etiologies, are addressed.
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Wright WF, Pinto CN, Palisoc K, Baghli S. Viral (aseptic) meningitis: A review. J Neurol Sci 2019; 398:176-183. [PMID: 30731305 DOI: 10.1016/j.jns.2019.01.050] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/17/2022]
Abstract
Viral meningitis is an inflammation of the meninges associated with acute onset of meningeal symptoms and fever, pleocytosis of the cerebrospinal fluid, and no growth on routine bacterial culture. It is sometimes associated with viral encephalitis and meningoencephalitis. Viruses reach the central nervous system (CNS) hematogenously or in a retrograde manner from nerve endings. The viral etiology varies according to age and country. Molecular diagnostics technology has helped improve the rate of pathogen detection reducing unnecessary antibiotic use and length of hospitalization. Most of the viral infections detailed in this article have no specific treatment other than supportive care. Many of the viruses discussed are preventable by vaccination and proper skin protection against transmitting vectors.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pinnacle, United States.
| | - Casey N Pinto
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pinnacle, United States; Department of Public Health Sciences, The Pennsylvania State University, United States.
| | - Kathryn Palisoc
- Division of Hospital Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pinnacle, United States
| | - Salim Baghli
- Division of Hospital Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pinnacle, United States
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Wright WF, Palisoc K, Baghli S. Mollaret meningitis. J Neurol Sci 2019; 396:148-149. [DOI: 10.1016/j.jns.2018.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
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Beaman MH. Community-acquired acute meningitis and encephalitis: a narrative review. Med J Aust 2018; 209:449-454. [PMID: 30309300 DOI: 10.5694/mja17.01073] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 08/31/2018] [Indexed: 12/26/2022]
Abstract
Meningitis and encephalitis are medical emergencies. Patients need prompt evaluation and immediate empiric therapy to reduce the likelihood of fatal outcomes and chronic neurological sequelae. Conjugate bacterial vaccines have significantly reduced the incidence of bacterial meningitis, especially in children. As the results of changes in patterns of bacterial drug sensitivity, ceftriaxone is now part of the recommended empiric treatment for bacterial meningitis and should be administered as early as possible. Neuroimaging delays the treatment of meningitis and is not needed in most cases. Adjunctive corticosteroid therapy is of benefit for many patients with meningitis and should be initiated in most adults before antibiotic therapy. Molecular testing can assist the specific diagnosis of encephalitis and should be based on the exposure history and geographic risk factors relevant to the patient, but non-infectious causes of encephalitis are also common. Empiric therapy for encephalitis should be directed at the most frequently identified infectious pathogen, herpes simplex virus type 1 (ie, intravenous aciclovir). Vaccines can protect against the major pathogens of childhood infections (measles, mumps, rubella, polio, varicella viruses), influenza viruses, and exotic pathogens that cause meningitis and encephalitis (rabies, Japanese encephalitis, dengue, yellow fever, tick-borne encephalitis viruses, Mycobacterium tuberculosis).
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Abstract
PURPOSE OF REVIEW The purpose of this review is to give an overview of viral meningitis and then focus in on some of the areas of uncertainty in diagnostics, treatment and outcome. RECENT FINDINGS Bacterial meningitis has been declining in incidence over recent years. Over a similar time period molecular diagnostics have increasingly been used. Because of both of these developments viral meningitis is becoming relatively more important. However, there are still many unanswered questions. Despite improvements in diagnostics many laboratories do not use molecular methods and even when they are used many cases still remain without a proven viral aetiology identified. There are also no established treatments for viral meningitis and the one potential treatment, aciclovir, which is effective in vitro for herpes simplex virus, has never been subjected to a clinical trial. SUMMARY Viruses are in increasingly important cause of meningitis in the era of declining bacterial disease. The exact viral aetiology varies according to age and country. Molecular diagnostics can not only improve the rate of pathogen detection but also reduce unnecessary antibiotics use and length of hospitalization. Further research is required into treatments for viral meningitis and the impact in terms of longer term sequelae.
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Henderson B, Kimberlin DW, Forgie SE. Delayed Recurrence of Herpes Simplex Virus Infection in the Central Nervous System After Neonatal Infection and Completion of Six Months of Suppressive Therapy. J Pediatric Infect Dis Soc 2017; 6:e177-e179. [PMID: 28379476 DOI: 10.1093/jpids/pix017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/10/2017] [Indexed: 11/14/2022]
Abstract
A 10-day-old child was treated for neonatal herpes simplex virus (HSV) central nervous system (CNS) disease with 21 days of intravenous acyclovir and 6 months of oral acyclovir. She presented 7 years later with HSV CNS disease and new lesions in her brain, illustrating the non-benign nature of delayed recurrent HSV CNS disease.
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Yoganathan KT, Cherif S, Rashid M, Yoganathan K. Acute recurrent lymphocytic meningitis in an immunocompetent HIV-positive African woman: Is it a Mollaret's meningitis or not? SAGE Open Med Case Rep 2017; 5:2050313X17722648. [PMID: 28835824 PMCID: PMC5564854 DOI: 10.1177/2050313x17722648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/20/2017] [Indexed: 11/17/2022] Open
Abstract
We report a case of acute recurrent meningitis in an HIV-positive immunocompetent woman. In this case, a 34-year-old African woman with a known HIV infection presented with symptoms of acute meningitis. She was on combination antiretroviral therapy with abacavir, lamivudine, and nevirapine. Her HIV RNA level was <70 IU/mL, and CD4 counts were 640 cells/mm3. This indicates that she was not immunocompromised. She was febrile on examination, with marked neck stiffness. Her cerebrospinal fluid revealed raised white cell counts with 100% lymphocytes and mildly raised protein. Polymerase chain reaction confirmed herpes simplex type 2 meningitis. She recovered fully with aciclovir 800 mg three times a day. However, she was readmitted with a similar presentation 5 months after the initial admission. Her cerebrospinal fluid confirmed recurrent herpes simplex type 2 meningitis. This case alerts the profession to the possibility of non-opportunistic infections in an immunocompetent HIV-positive patient and of herpes simplex virus type 2 causing recurrent lymphocytic meningitis.
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Affiliation(s)
| | - Soumeya Cherif
- Department of HIV/GUM, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Mariam Rashid
- Department of HIV/GUM, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Kathir Yoganathan
- Department of HIV/GUM, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
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Underdown SJ, Kumar K, Houldcroft C. Network analysis of the hominin origin of Herpes Simplex virus 2 from fossil data. Virus Evol 2017; 3:vex026. [PMID: 28979799 PMCID: PMC5617628 DOI: 10.1093/ve/vex026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Herpes simplex virus 2 (HSV2) is a human herpesvirus found worldwide that causes genital lesions and more rarely causes encephalitis. This pathogen is most common in Africa, and particularly in central and east Africa, an area of particular significance for the evolution of modern humans. Unlike HSV1, HSV2 has not simply co-speciated with humans from their last common ancestor with primates. HSV2 jumped the species barrier between 1.4 and 3 MYA, most likely through intermediate but unknown hominin species. In this article, we use probability-based network analysis to determine the most probable transmission path between intermediate hosts of HSV2, from the ancestors of chimpanzees to the ancestors of modern humans, using paleo-environmental data on the distribution of African tropical rainforest over the last 3 million years and data on the age and distribution of fossil species of hominin present in Africa between 1.4 and 3 MYA. Our model identifies Paranthropus boisei as the most likely intermediate host of HSV2, while Homo habilis may also have played a role in the initial transmission of HSV2 from the ancestors of chimpanzees to P.boisei.
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Affiliation(s)
- Simon J. Underdown
- Human Origins and Palaeoenvironmental Research Group (HOPE), Department of Anthropology & Geography, Oxford Brookes University, Oxford OX3 0BP, UK
- Leverhulme Centre for Human Evolutionary Studies, University of Cambridge, Henry Wellcome Building, Fitzwilliam Street, Cambridge CB2 1QH, UK
| | - Krishna Kumar
- Computational Geomechanics, Cambridge University Engineering Department, Trumpington Street, Cambridge CB2 1PZ, UK
| | - Charlotte Houldcroft
- Department of Archaeology, University of Cambridge, Cambridge CB2 3QG, UK
- McDonald Institute for Archaeological Research, University of Cambridge, Downing Street, Cambridge CB2 3ER, UK
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Cost-Effectiveness Study of Criteria for Screening Cerebrospinal Fluid To Determine the Need for Herpes Simplex Virus PCR Testing. J Clin Microbiol 2017; 55:1566-1575. [PMID: 28298450 DOI: 10.1128/jcm.00119-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/02/2017] [Indexed: 11/20/2022] Open
Abstract
The absence of markers of inflammation in the cerebrospinal fluid (CSF) commonly predicts the absence of herpes simplex virus (HSV) central nervous system (CNS) infection. Consequently, multiple authors have proposed and validated criteria for deferring HSV PCR testing of CSF in immunocompetent hosts with normal CSF white blood cell and protein levels (≤5 cells/mm3 and ≤50 mg/dl, respectively). Hosts are considered immunocompetent if they are ≥2 years old and have not had HIV or an organ transplant. Adoption of the criteria may erroneously exclude HSV-infected persons from a necessary diagnostic test or, alternatively, reduce the costs associated with HSV tests with minimal to no effect on patient care. Little is known about the cost-effectiveness of this approach. A decision analysis model was developed to evaluate the adoption of criteria for screening HSV tests of CSF. Estimates of input parameter values combined available literature with a multiyear multisite review at two of the largest health care systems in the United States. Adoption of criteria to screen for HSV test need proved cost-effective when less than 1 in 200 patients deferred from testing truly had an HSV CNS infection. Similar to prior studies, none of the deferred cases had HSV encephalitis (n = 3120). Adoption of these criteria in the United States would save an estimated $127 million ($95 million to $158 million [±25%]) annually. The model calculations remained robust to variation in test cost, prevalence of HSV infection, and random variation to study assumptions. The adoption of criteria to screen HSV PCR tests in CSF represents a cost-effective approach.
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Nakamura Y, Nakajima H, Kano Y, Unoda K, Ishida S, Kimura F. Herpes simplex virus type 2-associated recurrent aseptic meningitis (Mollaret's meningitis) with a recurrence after 11-year interval: a case report. Rinsho Shinkeigaku 2016; 56:785-787. [PMID: 27773908 DOI: 10.5692/clinicalneurol.cn-000950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 55-year-old woman was diagnosed with aseptic meningitis at the age of 43 and 44. She developed sudden fever and headache, and she showed nuchal rigidity. Cerebrospinal fluid examination revealed pleocytosis (cell count 208/mm3) and was positive for herpes simplex virus type 2 (HSV-2) DNA by PCR. Acyclovir was started on the first day of admission, and she was complete recovery. Preserved cerebrospinal fluid specimen from aseptic meningitis at the age of 44 was also positive for HSV-2 DNA by PCR. She was diagnosed with HSV-2 associated recurrent aseptic meningitis (Mollaret's meningitis) with a recurrence after 11-year interval. She repeatedly relapsed genital herpes after 44 years old and she was treated with valacyclovir whenever genital herpes relapses. But she showed no genital herpes at the onset of meningitis. Because HSV-2 is one of the most significant causes of recurrent meningitis, we would like to stress that HSV-2 infection and antiviral therapy should always be kept in mind for a recurrent meningitis case.
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Affiliation(s)
- Yoshitsugu Nakamura
- Division of Neurology, Department of Internal Medicine I, Osaka Medical College
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The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016; 72:405-38. [PMID: 26845731 DOI: 10.1016/j.jinf.2016.01.007] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 02/06/2023]
Abstract
Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.
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Kruis T, Kredel L, Nassir M, Godbersen M, Schneider T. Benigne rekurrierende aseptische Meningitis. Internist (Berl) 2016; 57:188-93. [DOI: 10.1007/s00108-015-0003-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Herpes simplex and varicella zoster CNS infections: clinical presentations, treatments and outcomes. Infection 2015; 44:337-45. [PMID: 26680781 DOI: 10.1007/s15010-015-0867-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the clinical manifestations, cerebrospinal fluid (CSF) characteristics, imaging studies and prognostic factors of adverse clinical outcomes (ACO) among adults with herpes simplex virus (HSV) or varicella zoster virus (VZV) CNS infections. METHODS Retrospective review of adult patients with positive HSV or VZV polymerase chain reaction on CSF from an observational study of meningitis or encephalitis in Houston, TX (2004-2014), and New Orleans, LA (1999-2008). RESULTS Ninety-eight adults patients were identified; 25 had encephalitis [20 (20.4 %) HSV, 5 (5.1 %) VZV], and 73 had meningitis [60 (61.1 %) HSV and 13 (13.3 %) VZV]. HSV and VZV had similar presentations except for nausea (P < 0.01) and rash (P < 0.001). The CSF profile did not differ between HSV and VZV infection. Abnormal neuroimaging findings were found in 11.6 % (10/86) brain CTs and 21.3 % (16/75) brain MRIs. The EEG was abnormal in 57.9 % (11/19). Sixteen patients (16.3 %) had an ACO (10 HSV encephalitis, 3 VZV encephalitis and 3 VZV meningitis). Intravenous acyclovir administered within 48 h was protective against an ACO [OR 0.19 (0.04-0.80), P = 0.02). However, on logistic regression only Charlson comorbidity score >1 and an encephalitis presentation were independently associated with an ACO. The treatment for HSV meningitis was variable, and all patients had a good clinical outcome. CONCLUSION Alpha herpes CNS infections due to HSV and VZV infections have similar clinical and laboratory manifestations. ACO was observed more frequently in those patients with comorbidities and an encephalitis presentation.
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Harris-Brown TM, Paterson DL. Reporting of pre-enrolment screening with randomized clinical trials: A small item that could impact a big difference. Perspect Clin Res 2015; 6:139-43. [PMID: 26229749 PMCID: PMC4504055 DOI: 10.4103/2229-3485.159937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Randomized controlled trials (RCTs), when conducted using ethical and transparent methods, become the ultimate standard for producing evidence-based knowledge in the field of medical research. We sought to determine the proportion of RCTs in which the number of screened patients is reported, and also to ascertain what predicted efficient screening (i.e., a high number of screened participants being enrolled). Materials and Methods: Thirty-five RCTs from the Journals Clinical Infectious Diseases and The Lancet Infectious Diseases were reviewed from the time period of January 2012 to July 2013 using standardised criteria. Results: From the 35 RCTs, 9 of 35 (26%) did not report the number of patients screened prior to recruitment. From the 26 studies that reported this screening figure, 10,215 (47%; range: 2-98%) of the screened participants (21,862) were subsequently enrolled. About 18.3% of those screened and not enrolled, met inclusion and exclusion criteria yet did not wish to participate in an RCT. Studies performed in developed countries and pediatric populations were more likely to have low rates of enrolment compared with the screened population although there was no statistical significance to these associations (P = 0.2 for both variables). Conclusion: Many reports of RCTs do not report screening figures, even though these add useful information about the feasibility of future trials.
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Affiliation(s)
- Tiffany M Harris-Brown
- Department of Infection and Immunity Theme, The University of Queensland, UQ Centre for Clinical Research, Herston, Brisbane, Queensland, Australia
| | - David L Paterson
- Department of Infection and Immunity Theme, The University of Queensland, UQ Centre for Clinical Research, Herston, Brisbane, Queensland, Australia
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Erdmann N, Hewitt BA, Atkinson TP, Van Wagoner N. Disseminated Primary Herpes Simplex Virus Type 2 Infection in a 22-Year-Old male. Open Forum Infect Dis 2015; 2:ofv092. [PMID: 26180838 PMCID: PMC4499671 DOI: 10.1093/ofid/ofv092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 06/10/2015] [Indexed: 12/13/2022] Open
Abstract
We present a case of primary disseminated herpes simplex virus type 2 (HSV-2) cutaneous disease in a 22-year-old male. We discuss the immune response to HSV-2 infection as well as the extragenital manifestations of HSV-2 observed in immune-competent and immune-suppressed persons.
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Fernandez-Gerlinger M, Greffe S, Meffre A, Grenet J, Au S, Bojanova M, Rouveix E, Rozenberg F. HSV-2 meningoencephalitis in an immunocompetent young man: what is the pathogenesis and what is the treatment? J Clin Virol 2015. [PMID: 26209376 DOI: 10.1016/j.jcv.2015.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Herpes simplex encephalitis is rarely caused by herpes simplex virus type 2 (HSV-2) after the neonatal period. The pathogenesis of HSV-2 encephalitis is not known and its treatment has not been discussed. We report a case of mild meningoencephalitis secondary to HSV-2 primary infection after sexual risk behaviour in a healthy young man. The diagnosis was established upon clinical, biological and electroencephalographic criteria. Aciclovir treatment led to rapid clinical improvement. This case highlights HSV-2 as a rare cause of meningoencephalitis, and questions the management of this rare manifestation of HSV-2 infection.
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Affiliation(s)
- Mp Fernandez-Gerlinger
- Service de médecine interne, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France; Université Versailles-Saint-Quentin-en-Yvelines, 78000 Versailles, France.
| | - S Greffe
- Service de médecine interne, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France
| | - A Meffre
- Service de médecine interne, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France
| | - J Grenet
- Service d'accueil des urgences, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France
| | - S Au
- Université Versailles-Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de réanimation médico-chirurgicale, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France
| | - M Bojanova
- Service de Virologie, Université Paris Descartes & Hôpitaux Universitaires Paris Centre, AP-HP, 75014 Paris, France
| | - E Rouveix
- Service de médecine interne, Hôpital Ambroise Paré, AP-HP, 92104 Boulogne-Billancourt, France; Université Versailles-Saint-Quentin-en-Yvelines, 78000 Versailles, France
| | - F Rozenberg
- Service de Virologie, Université Paris Descartes & Hôpitaux Universitaires Paris Centre, AP-HP, 75014 Paris, France
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Stuve O, Marder E, Okai A, Stettner M, Kieseier BC. Heat exposure and bicycling trigger recurrent aseptic meningitis: a case report. BMC Neurol 2014; 14:230. [PMID: 25551438 PMCID: PMC4301064 DOI: 10.1186/s12883-014-0230-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 11/19/2014] [Indexed: 11/10/2022] Open
Abstract
Background Aseptic meningitis associated with herpes simplex virus type 2 often has a relapsing-remitting clinical phenotype. Factors that lead to disease activation and reactivation are currently incompletely understood. Case presentation We describe the case of a 49-year-old Caucasian man who developed recurrent episodes of herpes simplex virus type 2-associated aseptic meningitis in the setting of heat exposure and bicycling. This case is compelling in that substantial data were available to the examining physicians on the amount of physical exercise and heat exposure. Strenuous physical activities or heat exposure in isolation did not cause re-occurrence of clinical signs and symptoms. Conclusions This case illustrates that the dual activation of mechanical and temperature receptors in dorsal root ganglia may lead to the recurrent reactivation and afferent dissemination of latent herpes simplex virus type 2 in some patients.
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Affiliation(s)
- Olaf Stuve
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA. .,Neurology Section, VA North Texas Health Care System, Medical Service, 4500 South Lancaster Rd, Dallas, TX, 75216, USA. .,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany. .,Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Ellen Marder
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA. .,Neurology Section, VA North Texas Health Care System, Medical Service, 4500 South Lancaster Rd, Dallas, TX, 75216, USA.
| | - Annette Okai
- Multiple Sclerosis Treatment Center of Dallas, Dallas, TX, USA.
| | - Mark Stettner
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Bernd C Kieseier
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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Noska A, Kyrillos R, Hansen G, Hirigoyen D, Williams DN. The role of antiviral therapy in immunocompromised patients with herpes simplex virus meningitis. Clin Infect Dis 2014; 60:237-42. [PMID: 25273082 DOI: 10.1093/cid/ciu772] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) are important causes of acute neurologic illness. Although the role of acyclovir in treating HSV encephalitis is clear, the role of antiviral therapy in HSV meningitis remains controversial. METHODS In this retrospective observational study, we reviewed the charts of all patients with cerebrospinal fluid specimens positive for HSV-1 or HSV-2 by polymerase chain reaction between July 2000 and November 2012. Patients' charts were reviewed for demographic data, clinical presentation, treatment, and clinical outcomes. RESULTS Forty-two patient-episodes were clinically classified as meningitis. In 6 episodes (14.3%), patients with meningitis received no antivirals, whereas the remaining episodes were treated with an oral antiviral (n = 11 [26.2%]), combination intravenous and oral therapy (n = 22 [52.4%]), or intravenous acyclovir alone (n = 3 [7.1%]). Six patients had recurrent episodes of meningitis and all recovered without any neurologic sequelae. Neurologic outcomes were significantly improved with antiviral therapy in immunocompromised patients with herpes meningitis (P < .05), but not in the 27 patient-episodes among immunocompetent patients (P = 1.0), as no neurologic sequelae were noted in this group. CONCLUSIONS Most patients with HSV meningitis rapidly improve, but immunocompromised hosts have more neurologic sequelae and may benefit from antiviral therapy. Our data suggest symptomatic treatment alone for immunocompetent patients with HSV meningitis, avoiding the cost and side effects of prolonged intravenous acyclovir therapy; in contrast, immunocompromised patients had improved outcomes and would therefore benefit from antiviral therapy.
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Affiliation(s)
- Amanda Noska
- Department of Infectious Diseases, Rhode Island Hospital and The Miriam Hospital, Brown University Affiliated Hospitals, Providence
| | - Ramona Kyrillos
- Department of Infectious Diseases, Lebanese Hospital University Medical Center, Beirut, Lebanon
| | - Glen Hansen
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center
| | - Diane Hirigoyen
- Department of Pathology and Laboratory Medicine, Hennepin County Medical Center
| | - David N Williams
- Departments of Medicine and Infectious Diseases, Hennepin County Medical Center and University of Minnesota Medical School, Minneapolis
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Abstract
Invasion of the central nervous system (CNS) by viral agents typically produces a meningoencephalitis in which either meningitis or encephalitis may predominate. Viruses may also infect cranial or spinal blood vessels to produce ischemic injury. Viral and other infections may also elicit a host immune response which is cross-reactive with components of the neural tissue, resulting in encephalomyelitis, transverse myelitis, injury to peripheral nerves, or optic neuritis. This chapter discusses the pathogenesis of CNS viral infections and reviews clinical features of these disorders, major agents responsible in immunocompromised and immunocompetent individuals, and treatment. Prion diseases and postinfectious viral CNS syndromes including postinfectious encephalomyelitis, acute hemorrhagic leukoencephalitis, cerebellar ataxia, and transverse myelitis are also discussed.
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Barker KR, Sarafino-Wani R, Khanom A, Griffiths PD, Jacobs MG, Webster DP. Encephalitis in an immunocompetent man. J Clin Virol 2013; 59:1-3. [PMID: 23829964 DOI: 10.1016/j.jcv.2013.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 05/17/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Kevin R Barker
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom.
| | - Robert Sarafino-Wani
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom
| | - Aysha Khanom
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom
| | - Paul D Griffiths
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom
| | - Michael G Jacobs
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom
| | - Daniel P Webster
- The Royal Free Foundation Trust, The Royal Free Hospital, Virology, Pond Street, London NW3 2QG, United Kingdom.
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Acute Viral Infections of the Central Nervous System in Immunocompetent Adults: Diagnosis and Management. Drugs 2013; 73:131-58. [DOI: 10.1007/s40265-013-0007-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Herpes simplex meningitis after removal of a vestibular schwannoma: case report and review of the literature. Otol Neurotol 2013; 33:1422-5. [PMID: 22975906 DOI: 10.1097/mao.0b013e3182693a03] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We present a case of postoperative herpes simplex type 1 viral meningitis after retrosigmoid craniotomy and uncomplicated removal of a vestibular schwannoma. This is a very rare complication that can mimic aseptic meningitis and could lead to devastating consequences for the patient, if unrecognized. PATIENT A healthy 49-year-old woman underwent retrosigmoid craniotomy and resection of a 2.4-cm vestibular schwannoma. She developed worsening headache and low-grade fever on postoperative Day 10 and underwent lumbar puncture showing a lymphocyte predominant pleocytosis. Polymerase chain reaction was positive for herpes simplex type 1 virus; bacterial cultures were negative. The patient subsequently developed a pseudomeningocele and mild hydrocephalus. INTERVENTION The patient was readmitted to the hospital, started on corticosteroids, and a lumbar drain was placed. She completed a 14-day course of antiviral therapy (4 d intravenous as an inpatient and 10 d oral outpatient therapy). RESULTS At 1 month follow-up, she was completely asymptomatic, and her pseudomeningocele had resolved. CONCLUSION The diagnosis of herpes simplex viral meningitis should be suspected in clinical cases of postsurgical meningitis with a lymphocyte predominant pleocytosis and negative bacterial cultures. Antiviral therapy should be initiated immediately after confirmatory polymerase chain reaction testing to avoid potential long-term sequelae of a herpes simplex infection of the central nervous system.
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