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Unusual course of herpes simplex virus encephalitis after acyclovir therapy

Ungewöhnlicher Verlauf einer Herpes Enzephalitis nach Acyclovir-Therapie

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Summary

This is a report on a case of herpes simplex encephalitis (HSE) taking an unusual course after initially successful acyclovir therapy. The etiology of HSE was proven serologically, by repeated detection of herpes simplex virus (HSV)-specific DNA sequences in cerebrospinal fluid (CSF) with polymerase chain reaction (PCR) and was supported by cerebral imaging. After both the neurological symptoms and laboratory findings had improved initially under acyclovir therapy, the patient's clinical condition deteriorated accompanied by a renewed increase in CSF pleocytosis and protein content. Nuclear magnetic resonance (NMR) imaging confirmed the finding of bilateral, mainly temporal lesions compatible with a diagnosis of relapsing HSE. The patient responded well to a second cycle of antiviral therapy but required a third treatment cycle due to renewed deterioration later on. HSV-specific DNA sequences could not be demonstrated in several consecutive CSF samples taken after the first week of illness but increased inflammatory changes typical of HSE were seen on NMR during phases of deterioration. IgM-class antibodies against HSV were detected in CSF 4 weeks after onset of symptoms and stayed positive for at least 7 weeks. Reasons for the repeated deterioration and possible explanations for the absence of HSV DNA in spite of what could be seen as relapses are discussed.

Zusammenfassung

Wir berichten über einen Fall von Herpes simplex-Virus-Enzephalitis (HSE), die nach anfänglich erfolgreicher Behandlung mit Acyclovir einen ungewöhnlichen Verlauf nahm. Die Diagnose einer HSE wurde serologisch und durch wiederholten Nachweis von HSV-spezifischen DNA-Sequenzen im Liquor cerebrospinalis geführt und durch zerebrale Bildgebung gestützt. Nachdem sich sowohl die neurologische Symptomatik als auch die Laborbefunde unter Therapie mit Acyclovir anfänglich gebessert hatten, verschlechterte sich in der Folge der klinische Zustand des Patienten wieder, einhergehend mit einer erneuten Zunahme von Pleozytose und Proteinkonzentration im Liquor. Kernspintomographisch zeigten sich beidseitige, vorwiegend temporal lokalisierte Läsionen, vereinbar mit der Diagnose eines Rückfalles der HSE. Der Patient reagierte gut auf einen zweiten antiviralen Therapiezyklus, benötigte anschließend aber wegen einer erneuten Verschlechterung einen dritten Therapiezyklus. HSV-spezifische DNA-Sequenzen konnten in mehreren nach Ablauf der ersten Krankheitswoche gewonnenen Liquorproben nicht nachgewiesen werden, doch zeigte die Kernspintomographie zunehmende, für eine HSE typische entzündliche Veränderungen während der Rückfälle. HSV-Antikörper der Klasse IgM konnten vier Wochen nach Erkrankungsbeginn erstmals im Liquor nachgewiesen werden und blieben über mindestens sieben Wochen nachweisbar. Ursachen für die wiederholten Verschlechterungen und mögliche Erklärungen für das Fehlen von HSV-DNA trotz vermuteter Rückfälle werden diskutiert.

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Authors and Affiliations

  1. Dept. of Virology, University College London Medical School, 46 Cleveland St., W1P 6DB, London, UK

    W. Preiser

  2. Laboratoire Lieners et Hastert, rue de l'Hôpital, L-9244, Diekirch, Luxembourg

    B. Weber

  3. Klinik für Neurologie, Zentrum der Neurologie und Neurochirurgie, Schleusenweg 2-16, D-60596, Frankfurt a. M.

    G. Klös & P. A. Fischer

  4. Zentrum der Hygiene, Institut für Medizinische Virologie, Paul-Ehrlich-Str. 40, D-60596, Frankfurt a. M., Germany

    H. W. Doerr

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  1. W. Preiser
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Preiser, W., Weber, B., Klös, G. et al. Unusual course of herpes simplex virus encephalitis after acyclovir therapy. Infection 24, 384–389 (1996). https://doi.org/10.1007/BF01716086

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  • DOI: https://doi.org/10.1007/BF01716086

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