Mollaret-like cells in patients with West Nile virus infection

A Case of West Nile Virus Neuroinvasive Disease Presenting With Isolated Diplopia

West Nile virus (WNV) is a single-stranded RNA virus causing a wide spectrum of diseases. Neuroinvasive conditions such as meningitis and encephalitis are feared complications of WNV infection. Here, we describe the case of a 78-year-old male whose only initial presenting symptoms were fever and transient diplopia, whose initial MRI imaging with and without contrast did not reveal any abnormalities. He was discharged, only to return to care the next day; lumbar puncture was performed suggesting bacterial meningitis, and he was admitted and given antibiotics. Repeat MRI was negative, and he developed an altered mental status requiring intubation. WNV neuroinvasive disease was subsequently found after serology was performed. Supportive care was given, and he made a full recovery with no residual deficits. This case highlights an unusual presentation of WNV encephalitis and highlights the difficulty that can be present in diagnosing this disease.

Mollaret's Meningitis: A Rare Entity

We report on a patient with Mollaret’s meningitis to highlight the appropriate diagnostic criteria and benign prognosis without empiric antiviral therapy. An 83-year-old man with a history of aseptic meningitis of unknown etiology followed by full recovery presented with a two-day history of fevers, generalized weakness, and neurologic abnormalities. Cerebral spinal fluid (CSF) analysis demonstrated lymphocytic pleocytosis consistent with aseptic meningitis. Given his prior noninfectious aseptic meningitis and symptom-free interval, Mollaret’s meningitis was suspected and empiric treatment for herpes simplex viruses (HSV) encephalitis with acyclovir was deferred. All CSF studies, including polymerase chain reactions for HSV-1 and HSV-2, returned negative with clinical improvement by the fourth day of admission. For patients suspected to have Mollaret’s meningitis, lumbar puncture should be conducted promptly to facilitate diagnosis. Although several reports describe patients with CSF infection, the diagnosis of Mollaret’s meningitis should be reserved for noninfectious cases. In such cases, empiric antiviral therapy for HSV encephalitis may be deferred and complete recovery is expected.

The role of chemokines in the pathogenesis of neurotropic flaviviruses

Neurotropic flaviviruses are important emerging and reemerging arthropod-borne pathogens that cause significant morbidity and mortality in humans and other vertebrates worldwide. Upon entry and infection of the CNS, these viruses can induce a rapid inflammatory response characterized by the infiltration of leukocytes into the brain parenchyma. Chemokines and their receptors are involved in coordinating complex leukocyte trafficking patterns that regulate viral pathogenesis in vivo. In this review, we will summarize the current literature on the role of chemokines in regulating the pathogenesis of West Nile, Japanese encephalitis, and tick-borne encephalitis virus infections in mouse models and humans. Understanding how viral infections trigger chemokines, the key cellular events that occur during the infection process, as well as the immunopathogenic role of these cells, are critical areas of research that may ultimately guide a much needed effort toward developing specific immunomodulators and/or antiviral therapeutics.

Mollaret meningitis may be caused by reactivation of latent cerebral toxoplasmosis

Mollaret meningitis (MM) occurs mainly in females and is characterized by recurrent episodes of headache, transient neurological abnormalities, and the cerebrospinal fluid containing mononuclear cells. HSV-2 was usually identified as the causative agent. Recently, we found that recurrent headaches in non-HIV-infected subjects were due to acquired cerebral toxoplasmosis (CT). The aim of the study was therefore to focus on molecular pathomechanisms that may lead to reactivation of latent CT and manifest as MM. Literature data cited in this work were selected to illustrate that various factors may affect latent CNS Toxoplasma gondii infection/inflammation intensity and/or host defense mechanisms, i.e., the production of NO, cytokines, tryptophan degradation by indoleamine 2,3-dioxygenase, mechanisms mediated by an IFN-gamma responsive gene family, limiting the availability of intracellular iron to T. gondii, and production of reactive oxygen/nitrogen species, finally inducing choroid plexitis and/or vasculitis. Examples of triggers revealing MM and accompanying disturbances of IFN-gamma-mediated immune responses that control HSV-2 and T. gondii include: female predominance (female mice are more susceptible to T. gondii infection than males); HSV-2 infection (increased IFN-gamma, IL-12); metaraminol (increased plasma catecholamine levels, changes in cytokine expression favoring T(H)2 cells responses); probably cholesterol contained in debris from ruptured epidermoid cysts (decreased NO; increased TNF-alpha, IL-6, IL-8). These irregularities induced by the triggers may be responsible for reactivation of latent CT and development of MM. Thus, subjects with MM should have test(s) for T. gondii infection performed obligatorily.

West Nile virus neuroinvasive disease

Since 1999, there have been nearly 20,000 cases of confirmed symptomatic West Nile virus (WNV) infection in the United States, and it is likely that more than 1 million people have been infected by the virus. WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future. Clinical syndromes produced by WNV infection include asymptomatic infection, West Nile Fever, and West Nile neuroinvasive disease (WNND). WNND includes syndromes of meningitis, encephalitis, and acute flaccid paralysis/poliomyelitis. The clinical, laboratory, and diagnostic features of these syndromes are reviewed here. Many patients with WNND have normal neuroimaging studies, but abnormalities may be present in areas including the basal ganglia, thalamus, cerebellum, and brainstem. Cerebrospinal fluid invariably shows a pleocytosis, with a predominance of neutrophils in up to half the patients. Diagnosis of WNND depends predominantly on demonstration of WNV-specific IgM antibodies in cerebrospinal fluid. Recent studies suggest that some WNV-infected patients have persistent WNV IgM serum and/or cerebrospinal fluid antibody responses, and this may require revision of current serodiagnostic criteria. Although there is no proven therapy for WNND, several vaccines and antiviral therapy with antibodies, antisense oligonucleotides, and interferon preparations are currently undergoing human clinical trials. Recovery from neurological sequelae of WNV infection including cognitive deficits and weakness may be prolonged and incomplete.

Recurrent Benign Lymphocytic Meningitis

Recurrent benign lymphocytic meningitis is a recurring, typically innocuous, painful form of aseptic meningitis. This syndrome is associated with transient neurological symptoms in one-half of afflicted patients. The causative agent is usually herpes simplex virus type 2, which can be confirmed by detection of viral DNA in the cerebrospinal fluid using polymerase chain reaction. Clinical disease resolves spontaneously; however, acyclovir, valacyclovir, and famciclovir have been administered to some patients for both episodic therapy and suppression of recurrences. This therapy is thought to be beneficial, although there is no controlled trial data to support efficacy and safety.

West Nile Virus: Epidemiology and Clinical Features of an Emerging Epidemic in the United States

West Nile virus (WNV) was first detected in North America in 1999 during an outbreak of encephalitis in New York City. Since then the virus has spread across North America and into Canada, Latin America, and the Caribbean. The largest epidemics of neuroinvasive WNV disease ever reported occurred in the United States in 2002 and 2003. This paper reviews new information on the epidemiology and clinical aspects of WNV disease derived from greatly expanded surveillance and research on WNV during the past six years.