Herpes simplex virus and Guillain-Barré polyradiculitis

A case of herpes simplex virus induced peripheral neuropathy and encephalitis with positive GM3 and CASPR2 antibody

BACKGROUND

We reported on a case involving an older patient with HSV-1 encephalitis who simultaneously experienced the onset of peripheral nerve symptoms associated with the presence of anti-GM3 immunoglobulin G (IgG).

CASE PRESENTATION

A 77-year-old male was admitted to hospital with high fever, weakness of both lower limbs, and an unstable gait. A CSF test revealed a strikingly increased protein level (1,002 mg/L, normative values: 150-450 mg/L) and MRI revealed hyper-signal lesions in the right temporal lobe, right hippocampus, right insula, and right cingulate gyrus. The CSF was positive for HSV PCR (HSV-1,17870). In addition, the serum samples were positive for CASPR2 antibodies (antibody titer: 1/10) and anti-GM3 immunoglobulin G (IgG) (+). The patient was diagnosed with HSV-1-induced peripheral nerve symptoms that were associated with encephalitis and the presence of anti-GM3 IgG and anti-CASPR2 antibodies. The patient had received included intravenous immunoglobulin, intravenous acyclovir, and corticosteroids therapy. At the one-year follow-up examination, he had regained the necessary skills associated with daily life.

CONCLUSIONS

Herpes simplex virus infection often induces encephalitis, and reaction to the virus may trigger an autoimmune response. Early diagnosis and treatment can avoid the progression of the disease to include autoimmune encephalitis.

COVID-19-Associated Bifacial Weakness with Paresthesia Subtype of Guillain-Barré Syndrome

We report a case of bifacial weakness with paresthesia, a recognized Guillain-Barré syndrome subtype characterized by rapidly progressive facial weakness and paresthesia without ataxia or other cranial neuropathies, which was temporally associated with antecedent coronavirus 2019 (COVID-19). This case highlights a potentially novel but critically important neurologic association of the COVID-19 disease process. Herein, we detail the clinicoradiologic work-up and diagnosis, clinical course, and multidisciplinary medical management of this patient with COVID-19. This case is illustrative of the increasingly recognized but potentially underreported neurologic manifestations of COVID-19, which must be considered and further investigated in this pandemic disease.

The Pathogenesis of the Demyelinating Form of Guillain-Barre Syndrome (GBS): Proteo-peptidomic and Immunological Profiling of Physiological Fluids

Acute inflammatory demyelinating polyneuropathy (AIDP) - the main form of Guillain-Barre syndrome-is a rare and severe disorder of the peripheral nervous system with an unknown etiology. One of the hallmarks of the AIDP pathogenesis is a significantly elevated cerebrospinal fluid (CSF) protein level. In this paper CSF peptidome and proteome in AIDP were analyzed and compared with multiple sclerosis and control patients. A total protein concentration increase was shown to be because of even changes in all proteins rather than some specific response, supporting the hypothesis of protein leakage from blood through the blood-nerve barrier. The elevated CSF protein level in AIDP was complemented by activization of protein degradation and much higher peptidome diversity. Because of the studies of the acute motor axonal form, Guillain-Barre syndrome as a whole is thought to be associated with autoimmune response against neurospecific molecules. Thus, in AIDP, autoantibodies against cell adhesion proteins localized at Ranvier's nodes were suggested as possible targets in AIDP. Indeed, AIDP CSF peptidome analysis revealed cell adhesion proteins degradation, however no reliable dependence on the corresponding autoantibodies levels was found. Proteome analysis revealed overrepresentation of Gene Ontology groups related to responses to bacteria and virus infections, which were earlier suggested as possible AIDP triggers. Immunoglobulin blood serum analysis against most common neuronal viruses did not reveal any specific pathogen; however, AIDP patients were more immunopositive in average and often had polyinfections. Cytokine analysis of both AIDP CSF and blood did not show a systemic adaptive immune response or general inflammation, whereas innate immunity cytokines were up-regulated. To supplement the widely-accepted though still unproven autoimmunity-based AIDP mechanism we propose a hypothesis of the primary peripheral nervous system damaging initiated as an innate immunity-associated local inflammation following neurotropic viruses egress, whereas the autoantibody production might be an optional complementary secondary process.

[Peripheral nervous system involvement in the course of herpes virus infections]

The herpes viruses are associated with both central and pe-ripheral nervous system complications. Patients with symptoms suggestive of herpes viruses infections coexisting with peri-phe-ral nervous system manifestations, especially Guillain-Barré syndrome, mononeuropathy, plexopathy and radiculopathy, should be screened for the herpes viruses infections in the differential diagnosis. The purpose of this review is to discuss the etiology, pathogenesis and treatment of the neuropathies in the course of herpes viruses infections.

Herpes virus infection of the peripheral nervous system

Among the human herpes viruses, three are neurotropic and capable of producing severe neurological abnormalities: herpes simplex virus type 1 and 2 (HSV-1 and HSV-2) and varicella-zoster virus (VZV). Both the acute, primary infection and the reactivation from the site of latent infection, the dorsal sensory ganglia, are associated with severe human morbidity and mortality. The peripheral nervous system is one of the major loci affected by these viruses. The present review details the virology and molecular biology underlying the human infection. This is followed by detailed description of the symtomatology, clinical presentation, diagnosis, course, therapy, and prognosis of disorders of the peripheral nervous system caused by these viruses.

Overlapping Guillain-Barré syndrome and Bickerstaff's brainstem encephalitis associated with anti-GQ1b IgG antibody after herpes simplex virus infection

Herpes simplex virus (HSV) is a rare, antecedent infectious agent in Guillain-Barré syndrome (GBS). We report a patient with overlapping GBS and Bickerstaff's brainstem encephalitis (BBE). The patient had a vesicular lesion on her nose. Antecedent HSV type 1 (HSV-1) infection was confirmed by isolation of the virus and detection of the presence of serum anti-HSV-1 IgM antibody during the acute phase. Her serum IgG had high anti-GQ1b antibody titer. External ophthalmoplegia has been noted in 2 of 4 reported cases of HSV-associated GBS. Herpetic brainstem encephalitis cases of poor prognosis are known, but only 2 cases of benign brainstem encephalitis secondary to HSV infection, in which there was acute ophthalmoplegia and clinical features consistent with those of BBE have been reported.

Herpes simplex virus specific antibody determined by immunoblotting in cerebrospinal fluid of a patient with the Guillain-Barré syndrome

The Guillain-Barré syndrome is often preceded by a herpes virus infection. Herpes simplex virus, however, has rarely been observed as the causative agent. A patient is described with a herpes simplex virus infection followed by a Guillain-Barré syndrome. Immunoblotting was used to detect herpes simplex virus-specific antibodies in serum and cerebrospinal fluid.

Rare association of herpes simplex virus IgM-specific antibodies and Guillain-Barré syndrome successfully treated with plasma exchange and immunosuppression

Herpes simplex virus (HSV) has been associated with various neurological disorders. In contrast, HSV infection is very rarely found in acute polyneuroradiculitis. In this report, a patient is described with a severe course of Guillain-Barr¿ syndrome (GBS). HSV IgM-specific antibodies and a rise of complement-fixation antibodies were detected. During the acute phase of neurologic syndrome, a nerve biopsy showed myelin damage and IgM deposits on the inner layer of the perineurium. Plasma exchange, in combination with immunosuppression, was successfully applied as a treatment in the relapsing course of GBS. Finally, after recovery, HSV-specific IgM antibodies disappeared.

Neurological infections caused by herpes simplex virus in adults

Over a period of 33 months, 281 neuro-infections were tested for herpes simplex virus. In 26 cases herpes simplex virus was identified as the aetiological agent by isolation of the virus from the cerebrospinal fluid and by serological tests. The illness took the form of severe encephalitis in four cases, less severe encephalitis or meningoencephalitis in 12 cases, aseptic meningitis in seven cases, meningo-encephalitis with radiculitis in one case, ascending radiculomyelitis in one case and radiculitis in one case. The diagnostical and therapeutical problems of herpes simplex neuro-infections are discussed.

Demyelination in allergic and Marek's disease virus induced neuritis. Comparative electron microscopic studies

Patterns of demyelination were studied in sciatic nerves, spinal roots and ganglia of chickens afflicted with either Marek's disease (MD) or experimental allergic neuritis (EAN). MD was induced in susceptible chicks after hatching by inoculation of the JM strain of MD Herpes virus. Tissues from these chickens were examined 7-83 days after infection. EAN was studied 10-21 days after sensitization of 4 week old chickens to emulsions containing human peripheral nerve with complete Freund's adjuvant. In both conditions lesions were encountered which consisted of perivenular infiltrates of mononuclear cells that penetrated the basal lamina of the neurolemmal sheath, displaced Schwann cells, lysed and stripped myelin lamellae without damage to axons. Other lesions in MD were characterized by lymphomatous infiltrates that contained necrotic cells and disintegrating axons. The similarity of the demyelinating process in MD to that seen in EAN suggests that MD virus infection activates lymphocytes sensitized to peripheral nerve myelin. The findings are discussed with reference to acute idiopathic polyneuritis (Guillain-Barré syndrome) in patients with preceding or concurrent Herpes virus infections including those known to cause lymphoproliferative disorders.

Herpes simplex virus-IgM specific antibodies in Guillain-Barré syndrome and encephalitis

Herpes simplex virus (HSV) has veen associated with a variety of inflammatory neurologic disorders. Recently we studied a patient with Guillain-Barré syndrome (GBS) following acute herpes vaginalis infection. Since IgM virus-specific antibody is thought to be a reliable indicator of acute viral infection, we employed a 2-h serologic assay for serum IgM antibodies to HSV using an indirect immunofluorescent technique. This patient demonstrated high serum IgM titers to HSV type 2 during the acute phase of her neurologic syndrome. The titer dropped substantially as convalescence progressed. A search for similar elevations in HSV-IgM specific antibody was made on sera from more than 70 other GBS patients. No other significant IgM antibody titers to either HSV type 1 or type 2 were found in this GBS series and a large number of neurologic controls. However, sera from two patients with a presumptive diagnosis of acute herpes encephalitis based on clinical and cerebrospinal fluid findings were positive, showing high titers in our test. The results of this study suggest that associated acute HSV infection is uncommon in GBS and an immunofluorescent seroassay of the type reported here may be a valuable noninvasive technique enabling the clinical laboratory to rapid confirm a diagnosis of herpes encephalitis.

Cytomegalovirus as a frequent cause of Guillain-Barré syndrome

In 10 patients with Guillain-Barré syndrome a preceeding cytomegalovirus infection could be demonstrated by virus-specific IgM antibodies that were present in high titers in 9 of the 10 patients in the first serum specimen. The IgM antibodies to cytomegalovirus were detected by a sensitive "double" indirect immunofluorescence technique. In most of our cases (8 of 10) the complement-fixing antibody titers had already reached high levels on admission into a hospital, and significant titer changes were not observed. Cytomegalovirus was isolated from the urine of five patients.

[Guillain Barré- polyneuroradiculitis and Fisher-syndrome in cytomegalovirus infections (author's transl)]

In seven patients suffering from polyneuroradiculitis of the Guillain-Barré type and one case of Fisher syndrome, a cytomegalovirus infection was found. The elevation of the virus-specific IgM-antibodies was confirmed in all cases. The clinical course was severe and acute with respiratory disturbances, but complete remission occurred within 1-4 months. The complement fixing antibodies were highest during the first week of illness, so that further elevations could not be demonstrated, therefore making the IgM-antibody method of special importance. The role of cytomegalovirus infections in polyneuroradiculitis is also discussed.