Virological diagnosis of herpes simplex encephalitis

doi:10.1016/S1386-6532(00)00069-X

Journal of Clinical Virology

Volume 17, Issue 1, June 2000, Pages 31-36

https://doi.org/10.1016/S1386-6532(00)00069-X Get rights and content

Abstract

Background: The herpes simplex encephalitis (HSE) represents one of the most severe infectious diseases of the central nervous system. As effective antiviral drugs are available, rapid and reliable diagnosis has become important. Objectives: To evaluate retrospectively the usefulness of polymerase chain reaction (PCR) as well as serological procedures for the diagnosis of HSE. Study design: 631 cerebrospinal fluids (CSF) from patients with clinical suspicion of encephalitis were tested for type-specific herpes simplex virus (HSV) DNA using PCR. Virus-specific antibodies including their intrathecal synthesis were measured in 624 CSF and 2409 serum samples of 2711 patients suspected of having encephalitis. Results: Positive results were obtained by PCR in eight patients (1.3%) for HSV-1 and in seven (1.1%) for HSV-2. Intrathecal antibody synthesis was estimated in 24 (3.8%) patients. In general, no intrathecal antibodies could be measured in patients with positive PCR results and vice versa the intrathecal immune response became positive when CSF was cleared from the HSV. Results of the antibody detection in serum specimens revealed an active HSV infection in 268 out of 2367 patients (11.3%). Conclusions: The detection of HSV-DNA by PCR is the method of choice for diagnosis of HSE in the early phase of the disease. During the later stage, it has to be diagnosed by the estimation of intrathecally synthesized antibodies.

Introduction

Herpes simplex encephalitis (HSE), associated with high mortality rates and serious sequelae in survivors represents one of the most severe infectious diseases of the central nervous system (CNS). The annual incidence is calculated as 1–4 per 1 million of the population. More than 90% of the cases are due to herpes simplex virus type 1 (HSV-1). The HSE may occur as a consequence of both primary as well as recurrent HSV infections and results in focal necrosis of the frontal and/or temporal lobes of the brain. Arising from herpes genitalis in pregnant women, HSV-2 may provoke hemorrhagic–necrotizing encephalitis via the bloodstream in neonates associated with dissemination to other organs. In adults, it has been suggested that virus transmission to the frontotemporal cortex results from the spread along the olfactory system. Less commonly, patients present with mild and subacute encephalitis, brainstem encephalitis, meningitis or myelitis.

Clinical symptoms suspected for HSE are most frequently diagnosed by infections specialists, neurologists, psychiatrists, paediatricians and neonatologists. The clinical diagnosis, however, is often unreliable, as numerous neurological syndromes may mimic HSE. For prognosis of the disease, it is important to achieve a rapid diagnosis, since mortality rate may only be decreased when antiviral therapy is initiated soon after the onset of symptoms (Whitley and Lakeman, 1995). With introducing molecular biological methods in the medical virology, polymerase chain reaction (PCR) has been proved to be the method of choice in the diagnosis of HSE (Puchhammer-Stöckl et al., 1993, Fomsgaard et al., 1998). Other procedures such as the estimation of virus-specific antibodies in serum and cerebrospinal fluid (CSF) samples have been so far also used.

In the present paper, the question about the usefulness of PCR in comparison with serological methods in the different stages of HSE should be answered. For this purpose, the virological diagnosis of HSE by PCR as well as detection of specific antibodies in sera and CSF samples should be retrospectively analysed.

Section snippets

Patients and clinical specimens

In the present study, 631 CSF and 2409 serum samples from 2711 hospitalized patients with clinical suspicion of encephalitis were enrolled. Their ages ranged between 6 days and 72 years (mean 43 years). The patients’ materials were submitted to the German reference centre for α-herpesviruses from 1987 to 1996 for diagnosing the HSV infection.

Polymerase chain reaction for detection of viral DNA in cerebrospinal fluid

The PCR was performed with oligonucleotide primer pairs specific for UL 42 region of HSV-1 and thymidine kinase gene of HSV-2, respectively (Table 1).

Results

The investigation of 631 CSF specimens by PCR revealed HSV-1 DNA sequences in eight and HSV-2 DNA sequences in seven patients (Table 2, Fig. 1). Positive CSF samples were obtained within 3–12 days (median 7.3 days) after onset of neurological symptoms. PCR results were available within one day, cross-reactions were not observed. From these data, a positive rate of 2.4% could be calculated. The detection of HSV DNA in CSF was considered to be direct confirmation of CNS infection by HSV. In all

Discussion

HSE can be treated successfully if the disease is diagnosed in the early stage. However, the clinical diagnosis is unreliable due to the fact that a lot of different microorganisms may cause encephalitis. An early and accurate confirmation of HSE may only be possible by identification of the etiological agent in the brain or CSF. Previous investigations have been restricted to the isolation of virus in cell cultures and/or the direct staining of viral antigens in brain biopsy material (

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Virological diagnosis of herpes simplex encephalitis

Abstract

Introduction

Section snippets

Patients and clinical specimens

Polymerase chain reaction for detection of viral DNA in cerebrospinal fluid

Results

Discussion

Lancet

J. Virol. Methods

Clin. Diagn. Virol.

J. Virol. Methods

Clin. Diagn. Virol.

Clin. Diagn. Virol.

J. Clin. Virol.

Am. J. Med.

Herpes simplex virus encephalitis. New diagnostic and clinical features and results of therapy

Arch. Neurol.