Birgit Sköldenberg

Rapid diagnosis of herpes simplex encephalitis by nested polymerase chain reaction assay of cerebrospinal fluid

With the aim of improving early diagnosis of herpes simplex encephalitis a polymerase chain reaction (PCR) assay with two nested primer pairs was developed for the amplification of herpes simplex virus DNA in cerebrospinal fluid (CSF). Southern blotting was used to confirm the specificity of the amplification. The assay was applied to 151 CSF samples from 43 consecutive patients with herpes simplex encephalitis verified by the finding of herpes simplex virus/viral antigen in a brain biopsy sample or at necropsy (13) and/or intrathecal production of IgG antibody to the virus (40). As controls, 87 CSF samples from 60 patients with acute febrile focal encephalopathy (initially suspected to be herpes simplex encephalitis but excluded by the absence of intrathecal antibody synthesis) were tested. PCR detected herpes simplex virus DNA in 42 of the 43 patients with proven herpes simplex encephalitis; all but 1 were positive in the first CSF sample taken. The 1 PCR-negative patient had been treated with acyclovir from 20 h after the onset of symptoms. All the control subjects were PCR negative, as were 270 internal contamination controls. The PCR result remained positive in samples drawn up to 27 days after the onset of neurological symptoms. This method is a rapid and non-invasive means to diagnose herpes simplex encephalitis; it is highly sensitive and specific.

ACYCLOVIR VERSUS VIDARABINE IN HERPES SIMPLEX ENCEPHALITIS: Randomised Multicentre Study in Consecutive Swedish Patients

One hundred and twenty-seven patients with suspected herpes simplex encephalitis were entered in a randomised, controlled comparative study of therapy with acyclovir 10 mg/kg, 8-hourly, versus vidarabine, 15 mg/kg daily, for 10 days. Consecutive patients were included and nearly all diagnosed cases of HSV-encephalitis in Sweden were enrolled in the study. The diagnosis of HSV-encephalitis was verified by demonstration of intrathecal herpes simplex virus (HSV) antibody production and by HSV cultivation, or antigen detection, in brain biopsy or necropsy material. Of 53 confirmed cases of HSV-encephalitis (corresponding to 2.3 cases per million inhabitants per year in Sweden), 51 (27 acyclovir, 24 vidarabine) were evaluable for therapeutic efficacy. The mortality was 19% in the acyclovir-treated group versus 50% in the vidarabine group (p = 0.04). At 12 month of observation 15 of 27 (56%) acyclovir recipients had no, or mild, sequelae compared with 3 of 24 (13%) vidarabine recipients (p = 0.002). Nineteen of 24 (79%) vidarabine-treated patients died or suffered severe sequelae, compared with 9 of 27 (33%) acyclovir-treated patients (p = 0.005). The effect of treatment was influenced by the level of consciousness at the start of therapy. The outcome for 20 vidarabine-treated patients above 30 years of age with HSE was similar to that for the 53 patients reported by an American collaborative study.

Herpes simplex encephalitis in Sweden, 1990-2001: incidence, morbidity, and mortality.

BACKGROUNDnHerpes simplex encephalitis (HSE) is a devastating disease.nnnMETHODSnIn Sweden, a nationwide retrospective study of the incidence, morbidity, and mortality associated with HSE during the 12-year period 1990-2001 was conducted. The national inpatient register data were used, and diagnostic data from the virus laboratories were validated.nnnRESULTSnIn the study period, 638 patients hospitalized in Sweden received a primary diagnosis of HSE. Of these, 236 patients had a confirmed infection of the central nervous system due to herpes simplex virus type 1. This corresponds to an incidence of confirmed HSE due to herpes simplex virus type 1 of 2.2 cases per million population per year. Of the survivors, 87% were readmitted to the hospital. The most frequent diagnosis at readmission was epilepsy, which was found in 49 patients (21% of the 236 total patients; 24% of 203 survivors), with a median onset 9.3 months after the diagnosis of HSE. This corresponds to a 60- to 90-fold increase in risk, compared with that for the general population. Neuropsychiatric sequelae were evident in 45 (22%) of 203 surviving patients. The incidence of venous thromboembolism, including pulmonary embolism, was 5-14 times higher than that in the general population. Among patients with HSE due to herpes simplex virus type 1, the 1-year mortality was 14% (33 of 236 patients died), which was 8 times higher than expected.nnnCONCLUSIONSnThis is, to our knowledge, the first study to report long-term, nationwide follow-up data for patients with virologically confirmed HSE. There is considerable morbidity after HSE, with epilepsy being the most common diagnosis. This demonstrates the need for expanding our knowledge of the pathogenesis of HSE to direct more effective antiviral and antiinflammatory treatments.

Incidence and pathogenesis of clinical relapse after herpes simplex encephalitis in adults

ObjectivesTo study the occurrence of relapse of herpes simplex encephalitis (HSE) and to find out whether soluble activity markers in cerebrospinal fluid (CSF) indicate direct viral or immune– mediated events.MethodsA consecutive series of 32 adult survivors of HSE were followed to determine the incidence of clinical relapse of HSE. Four patients had neurological deterioration interpreted as relapsing HSE. Four non–relapsing HSE cases were selected as matched controls. Fiftynine batched, paired CSF and serum samples from the eight HSE patients were analysed for soluble activity markers, predominantly cytokines and mediators (interferon– γ, soluble CD8, tumour necrosis factor–α, and interleukin–10), amount of HSV–DNA and markers of glial and neuronal destruction (neurofilament protein, glial fibrillary acidic protein, S–100–β, and neuron specific enolase).ResultsRelapse of HSE was diagnosed in 3 of 26 (12 %) acyclovir–treated patients (5 episodes during 6.1 years of followup) and in 1 of 6 vidarabine–recipients. All relapses occurred from 1 to 4 months after acute HSE, except for a second relapse after 3.3 years in one patient. Computer tomography at relapses revealed few abnormalities apart from those found during the primary disease. Intravenous acyclovir and corticosteroids were given for 7–21 days in all the relapse patients. All relapse patients seemed to recover to the pre–relapse condition. HSV–DNA was demonstrated in CSF in all patients during the acute stage but not in any of 13 CSF samples taken during relapse phases. The HSV viral load during the acute stage of HSE was not higher or of longer duration in the relapsing patients than in the non–relapsing HSE controls. The levels of sCD8 were increased in nearly all CSF samples tested with peaks of sCD8 at one month of acute HSE. In all episodes of relapse, sCD8 peaks were detected during the first week at high levels. CSF levels of neuron–specific enolase, S–100 and glial fibrillary acidic protein were markedly lower at relapse than at the acute stage of HSV–1 encephalitis.ConclusionThe lack of demonstrable HSV DNA in CSF, the lack of acute CSF signs and the lack of signs of neural and glia cells destruction indicate that a direct viral cytotoxicity is not the major pathogenic mechanism in relapse. Instead, the pronounced CSF proinflammatory immunological response and the relative lack of CSF anti–inflammatory cytokine IL–10 response suggest immunologically–mediated pathogenicity.

Clinical Manifestations and Diagnosis of Neuroborreliosis

Lyme borreliosis has in a few years turned out to be a health problem not only in the United States, but also in many European countries. When it affects the nervous system, Lyme borreliosis acts as the great disease imitator. Because of this characteristic it is often difficult to diagnose on clinical grounds. Patients with neuroborreliosis might appear within all medical disciplines. Clinical markers, such as preceding tick bite and/or ECM, are important clues to the diagnosis. Mononuclear pleocytosis and elevated CSF protein are present in most patients with neuroborreliosis. Final evidence for the diagnosis is the demonstration of specific antibodies in serum and/or CSF. Measurement of antibody titers should be carried out in both serum and CSF, since these methods are complementary when trying to obtain a serological diagnosis of neuroborreliosis.

Intrathecal IgM, IgA and IgG antibody response in tick-borne encephalitis. Long-term follow-up related to clinical course and outcome.

BACKGROUNDnTick-borne encephalitis (TBE) of western subtype causes long-term morbidity and is considered a health problem in Scandinavia, eastern and central parts of Europe and Russia. The pathophysiology is not fully elucidated. As TBE RNA is rarely demonstrable in cerebrospinal fluid (CSF) the kinetics of the CSF antibody response to the disease has attracted attention.nnnOBJECTIVESnTo investigate the intrathecal TBE-specific antibody response and to correlate its intensity and persistence to the clinical course. To compare indirect, commercially-based ELISA methods indexed against albumin ratio or IgG ratio with the capture ELISA method for the establishment of CSF response.nnnSTUDY DESIGNnThe specific IgM, IgG and IgA antibody responses in serum and CSF were analysed in 69 Swedish patients included in a prospective study of TBE from the acute phase up to 11-13 months after onset.nnnRESULTSnAntibody response by all three classes was demonstrable in serum and CSF. All methods were useful, but capture technique was the most sensitive and results were easiest to interpret. Peak IgM activity was seen early during the disease and persisted after 6 weeks. Maximum IgG levels were encountered in late convalescent samples (median 6 weeks). Intrathecal antibody production was demonstrable in nearly all patients: in 41% days 0-6, in 97% days 7-19, in 98% days 21-61 and-at lower levels-in 84% of the patients after 1 year (50/52 of CSF-serum sampled in the interval 11-61 days). Day 9 after onset, patients with dominating encephalitic symptoms showed significantly lower intrathecal IgM activity. The persistence of serum and CSF antibodies did not correlate to severity of disease.nnnCONCLUSIONSnCapture IgM and IgG assays were superior to indirect ELISA. Low early CSF IgM response correlated to encephalitic symptoms, otherwise the intensity and duration of intrathecal antibody response were of limited value for the prediction of clinical course and long-term outcome.

Long-term persistence of intrathecal virus-specific antibody responses after herpes simplex virus encephalitis.

SummaryPaired sera and cerebrospinal fluids (CSF) from nine surviving patients were collected 4.5 to 8 years after acute herpes simplex (HS) virus encephalitis. Oligoclonal bands of IgG were detected in the CSF of all, and seven patients had an elevated CSF IgG index. Antibodies to HS, varicella-zoster (VZ), measles, and cytomegalo viruses were analysed by enzyme-linked immunosorbent assay (ELISA) and by imprint immunofixation (IIF) of specimens separated by electrophoresis and by thin-layer electrofocusing. Intrathecal synthesis of HS and VZ IgG antibodies was demonstrated in all and of measles IgG antibodies in one patient by both methods. Intrathecal synthesis of HS IgA antibodies was demonstrated by ELISA in three and by IIF in seven patients; the latter method also disclosed intrathecal synthesis of VZ IgA antibodies in two. No patient had intrathecal synthesis of viral IgM antibodies. The intrathecally synthesized antibodies demonstrated by IIF displayed oligoclonal characteristics. The IIF analyses as well as virus absorption tests indicated that the intrathecally synthesized VZ IgG and IgA antibodies could be explained as HS antibodies cross-reacting with VZV. The results indicate that a long-term persistence of intrathecal antibody reesponses to HS virus is a common feature after acute HS encephalitis. The intrathecal production of measles IgG antibodies in one case may reflect a similar persistence of non-specific immune responses induced during the acute infection.

CHRONIC MENINGITIS CAUSED BY A PENICILLIN-SENSITIVE MICROORGANISM?

21 patients studied had persistent or progressive chronic meningitis not associated with a demonstrable infectious or other disease, except Streptococcus milleri antigen in the cerebrospinal fluid of 1 patient. The cerebrospinal-fluid (CSF) abnormalities consisted of a moderate, predominantly mononuclear, pleocytosis, a sharp rise in CSF protein (mean 2.3 g/l), intrathecal synthesis of considerable quantities of oligoclonal immunoglobulin G, and, in half the patients, a fall in the CSF-glucose/blood-glucose ratio. In all patients symptoms began during summer or autumn. In 4 patients the onset was preceded by localised cutaneous lesion, described as erythema chronicum migrans. 4 more patients had been bitten by ticks in the weeks before onset of symptoms. The patients had profound fatigue, malaise, and weight-loss. Half had fever, usually moderate. The neurological abnormalities included aseptic meningitis, cranial neuropathy (mostly facial-nerve paralysis), motor and sensory peripheral radiculoneuropathy, and myelitis. The patients improved or recovered, sometimes dramatically, during a 2-week course of intravenous penicillin G.

HIV isolation from cerebrospinal fluid in relation to immunological deficiency and neurological symptoms

Human immunodeficiency virus (HIV) could be isolated from the cerebrospinal fluid (CSF) of the majority (62%) of 72 patients in various stages of HIV infection. This high rate of successful virus isolation was achieved only when the time from lumbar puncture to initiation of the cell cultures was short, i.e. not exceeding 5 h. The HIV isolation rates were equally high in patients with persistent generalized lymphadenopathy (PGL), AIDS-related complex (ARC) and AIDS. Although the HIV recovery rate was low in patients with normal immunological parameters it was not correlated with the degree of severity of the immunodeficiency in the other patients. Furthermore, the recovery rates were not significantly correlated to the duration of the infection. HIV was recovered as often from patients with neurological symptoms as from patients without such symptoms. These findings suggest that in the majority of patients there is central nervous system (CNS) involvement early in the course of HIV infection and that HIV replication in the CNS may occur in the absence of a pronounced systemic cellular immunodeficiency and frequently without causing overt neurological symptoms.

Acyclovir treatment in infectious mononucleosis: A clinical and virological study

Fifty-six patients with a clinical and laboratory diagnosis of infectious mononucleosis who had not been ill for more than seven days, were randomised for peroral treatment with acyclovir (800 mg five times daily) or placebo for seven days in a double blind trial. Clinical, virological and immunological parameters were monitored in each patient for six months. During treatment, shedding of Epstein-Barr virus as assessed in 36 patients, was significantly reduced (p<0.001). However, virus production in the oropharynx returned to pre-treatment levels one week after the cessation of therapy. Virus was detected in 35 patients at enrollment and in 28 of 36 patients at the six-month control. No effect on the clinical course of the disease was noticed. The virus-specific antibody response was also unaffected. A significant reduction in spontaneous outgrowth ofin vivo Epstein-Barr virus-infected B-lymphocytes was found at 180 days after treatment in four acyclovir-treated patients compared to six controls (p<0.001). In another three patients with over-whelming clinical symptoms causing airway obstruction and/or disseminated intravascular coagulopathy, treatment with intravenous acyclovir (10 mg/kg three times daily) was combined with prednisolone (0.7 mg/kg daily) for ten days. Virus shedding ceased transiently during treatment, but returned to initial levels within one week. A dramatic clinical effect on the pharyngeal oedema and general health of the two patients with airway obstruction was noticed, but was much less evident in a patient with intravascular coagulopathy. Bei 56 Patienten mit klinisch und durch Laborparameter gesicherter infektiöser Mononukleose und Krankheitsdauer von nicht mehr als sieben Tagen wurde im Rahmen einer Doppelblindstudie entweder eine orale Therapie mit 800 mg Aciclovir fünfmal täglich oder mit Placebo über sieben Tage durchgeführt. Bei allen Patienten wurden sechs Monate lang klinische, virologische und immunologische Parameter überwacht. Unter der Therapie war bei 36 überprüften Patienten die Ausscheidung von Epstein-Barr-Virus signifikant vermindert (p<0,001). Eine Woche nach Therapieende war die Virusproduktion im Oropharynx jedoch wieder so ausgeprägt wie vor der Therapie. Bei Aufnahme in die Studie wurde bei 35 der 36 Patienten der Therapiegruppe Epstein-Barr-Virus nachgewiesen, sechs Monate nach Therapieende bei 28 Patienten. Ein Einfluß der Therapie auf den klinischen Verlauf der Erkrankung konnte nicht festgestellt werden. Die spezifische Antikörperantwort auf das Virus war ebenfalls unbeeinflußt. 180 Tage nach Therapieende fand sich bei vier der mit Aciclovir behandelten und bei sechs der Patienten der Kontrollgruppe eine signifikante Verminderung des spontanen Wachstums von mit Epstein-Barr-Virus infizierten Lymphozytenin vivo (p<0,001). Bei drei weiteren Patienten mit schwersten klinischen Symptomen mit Atemwegsverlegung und/oder disseminierter intravasaler Koagulopathie wurde eine kombinierte Therapie mit dreimal täglich 10 mg Aciclovir/kg i. v. und 0,7 mg Prednisolon/kg täglich über zehn Tage durchgeführt. Die Virusausscheidung sistierte vorübergehend unter der Behandlung, kehrte jedoch innerhalb einer Woche nach Therapie wieder zu den Anfangswerten zurück. Die Kombinationstherapie führte bei zwei der Patienten mit Atemwegsobstruktion zu einer dramatischen Besserung des Pharynxödems und des Allgemeinzustandes, bei dem Patienten mit intravasaler Koagulopathie war die Wirkung sehr viel weniger ausgeprägt.SummaryFifty-six patients with a clinical and laboratory diagnosis of infectious mononucleosis who had not been ill for more than seven days, were randomised for peroral treatment with acyclovir (800 mg five times daily) or placebo for seven days in a double blind trial. Clinical, virological and immunological parameters were monitored in each patient for six months. During treatment, shedding of Epstein-Barr virus as assessed in 36 patients, was significantly reduced (p<0.001). However, virus production in the oropharynx returned to pre-treatment levels one week after the cessation of therapy. Virus was detected in 35 patients at enrollment and in 28 of 36 patients at the six-month control. No effect on the clinical course of the disease was noticed. The virus-specific antibody response was also unaffected. A significant reduction in spontaneous outgrowth ofin vivo Epstein-Barr virus-infected B-lymphocytes was found at 180 days after treatment in four acyclovir-treated patients compared to six controls (p<0.001). In another three patients with over-whelming clinical symptoms causing airway obstruction and/or disseminated intravascular coagulopathy, treatment with intravenous acyclovir (10 mg/kg three times daily) was combined with prednisolone (0.7 mg/kg daily) for ten days. Virus shedding ceased transiently during treatment, but returned to initial levels within one week. A dramatic clinical effect on the pharyngeal oedema and general health of the two patients with airway obstruction was noticed, but was much less evident in a patient with intravascular coagulopathy.ZusammenfassungBei 56 Patienten mit klinisch und durch Laborparameter gesicherter infektiöser Mononukleose und Krankheitsdauer von nicht mehr als sieben Tagen wurde im Rahmen einer Doppelblindstudie entweder eine orale Therapie mit 800 mg Aciclovir fünfmal täglich oder mit Placebo über sieben Tage durchgeführt. Bei allen Patienten wurden sechs Monate lang klinische, virologische und immunologische Parameter überwacht. Unter der Therapie war bei 36 überprüften Patienten die Ausscheidung von Epstein-Barr-Virus signifikant vermindert (p<0,001). Eine Woche nach Therapieende war die Virusproduktion im Oropharynx jedoch wieder so ausgeprägt wie vor der Therapie. Bei Aufnahme in die Studie wurde bei 35 der 36 Patienten der Therapiegruppe Epstein-Barr-Virus nachgewiesen, sechs Monate nach Therapieende bei 28 Patienten. Ein Einfluß der Therapie auf den klinischen Verlauf der Erkrankung konnte nicht festgestellt werden. Die spezifische Antikörperantwort auf das Virus war ebenfalls unbeeinflußt. 180 Tage nach Therapieende fand sich bei vier der mit Aciclovir behandelten und bei sechs der Patienten der Kontrollgruppe eine signifikante Verminderung des spontanen Wachstums von mit Epstein-Barr-Virus infizierten Lymphozytenin vivo (p<0,001). Bei drei weiteren Patienten mit schwersten klinischen Symptomen mit Atemwegsverlegung und/oder disseminierter intravasaler Koagulopathie wurde eine kombinierte Therapie mit dreimal täglich 10 mg Aciclovir/kg i. v. und 0,7 mg Prednisolon/kg täglich über zehn Tage durchgeführt. Die Virusausscheidung sistierte vorübergehend unter der Behandlung, kehrte jedoch innerhalb einer Woche nach Therapie wieder zu den Anfangswerten zurück. Die Kombinationstherapie führte bei zwei der Patienten mit Atemwegsobstruktion zu einer dramatischen Besserung des Pharynxödems und des Allgemeinzustandes, bei dem Patienten mit intravasaler Koagulopathie war die Wirkung sehr viel weniger ausgeprägt.