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HERPES SIMPLEX ENCEPHALITIS IN OLDER ADULTS

2010; Wiley; Volume: 58; Issue: 1 Linguagem: Inglês

10.1111/j.1532-5415.2009.02655.x

1532-5415

Antoni Riera‐Mestre, Ana Requena‐Méndez, Sergio Martínez‐Yélamos, Carmen Cabellos, P Fernández-Viladrich,

Cytomegalovirus and herpesvirus research

Journal of the American Geriatrics SocietyVolume 58, Issue 1 p. 201-202 LETTERS TO THE EDITORFree Access HERPES SIMPLEX ENCEPHALITIS IN OLDER ADULTS Antoni Riera-Mestre MD, Antoni Riera-Mestre MD Department of Internal MedicineSearch for more papers by this authorAna Requena MD, Ana Requena MD Department of Internal MedicineSearch for more papers by this authorSergio Martínez-Yelamos MD, Sergio Martínez-Yelamos MD Department of NeurologySearch for more papers by this authorCarmen Cabellos MD, Carmen Cabellos MD Department of Infectious Diseases, Hospital Universitari de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, SpainSearch for more papers by this authorPedro Fernández-Viladrich MD, Pedro Fernández-Viladrich MD Department of Infectious Diseases, Hospital Universitari de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, SpainSearch for more papers by this author Antoni Riera-Mestre MD, Antoni Riera-Mestre MD Department of Internal MedicineSearch for more papers by this authorAna Requena MD, Ana Requena MD Department of Internal MedicineSearch for more papers by this authorSergio Martínez-Yelamos MD, Sergio Martínez-Yelamos MD Department of NeurologySearch for more papers by this authorCarmen Cabellos MD, Carmen Cabellos MD Department of Infectious Diseases, Hospital Universitari de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, SpainSearch for more papers by this authorPedro Fernández-Viladrich MD, Pedro Fernández-Viladrich MD Department of Infectious Diseases, Hospital Universitari de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, SpainSearch for more papers by this author First published: 04 January 2010 https://doi.org/10.1111/j.1532-5415.2009.02655.xCitations: 5AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat To the Editor: Herpes simplex encephalitis (HSE) is the most frequent cause of sporadic necrotizing encephalitis in adults.1,2 HSE has a bimodal distribution, with one-third of patients younger than 20 and half aged 50 and older.3,4 Nevertheless, few data have been reported about HSE in older adults.3,5 The aim of this study was to describe the characteristics of an elderly subgroup of a larger series of inpatient adults.6 Inpatients aged 65 and older with a consistent clinical profile and a positive polymerase chain reaction (PCR) for herpes simplex virus (HSV) in the cerebrospinal fluid (CSF) or compatible neuroimaging of the brain were included. A compatible clinical profile was established when patients showed symptoms or signs consistent with central nervous system dysfunction of acute or subacute onset and an altered level of consciousness or fever. Neuroimaging of the brain was considered positive in the presence of hypodense images on computed tomography (CT) or hyperintense lesions in the temporal lobes or the orbitobasal region of the frontal lobes (unilaterally or bilaterally) in T2 and fluid-attenuated inversion recovery sequences on magnetic resonance imaging (MRI). An electroencephalographic study (EEG) was defined as positive if it showed focal slow waves, spikes, or spike-waves. Functional status was measured using the Barthel Index for basic activities of daily living. Cognitive function was measured using the Pfeiffer questionnaire after 6 months of follow-up. The Charlson Index was used to measure overall comorbidity. Neurological sequelae were evaluated and measured using the modified Rankin scale (mRS) at discharge and after a follow-up period of 6 months. Patients were divided into two groups according to the mRS: good outcome (≤Grade 2) and poor outcome (≥Grade 3).7 Twelve patients were studied. Demographic and clinical characteristics, diagnostic tests, and clinical course of these patients are summarized in Table 1. No patients were at Stage 3 or higher on the Global Deterioration Scale (GDS), and no dementia had been diagnosed before admission. The temporal lobe was affected in all, and in two (16.6%) patients, the involvement was bilateral. All patients received acyclovir for a mean of 14 days (range 12–20 days), 11 (91.7%) also received antiepileptic drugs (in 7 patients as treatment and in 4 patients as prophylaxis), and five (41.7%) patients were treated with dexamethasone for intracranial hypertension. The mean duration between starting acyclovir and the first day of apyrexia was 11 days (range 3–21 days). Four patients (33.3%) required admission to the intensive care unit (ICU), all of them needing orotracheal intubation for mechanical ventilation. At discharge, nine (75%) patients were found to have poor outcome, with a hospital mortality of three (25%) patients. After 6 months, three (33.3%) patients continued to have poor outcome, without any new deaths, according to the mRS. Table 1. Demographic and Clinical Characteristics, Diagnostic Tests, and Clinical Course Variable Value Age, median (range) 76 (67–89) Male, n/N (%) 8/12 (66.7) Charlson Index, median (range) 2.5 (1–4) Barthel Index, median (range) Prior to admission 92 (80–100) At admission 49 (20–90) At discharge 53 (25–80) At 6 months 75 (50–100) Diagnosed dementia at admission, n/N (%) 0/12 (0) Pfeiffer questionnaire after 6 months of follow-up, median (range)* 1.5 (0–3) Season at admission, n/N (%) Spring 2/12 (16.6) Summer 1/12 (8.3) Autumn 4/12 (33.3) Winter 5/12 (41.6) Symptoms at prehospitalization, days, median (range) 5 (3–7) Behavioral changes, n/N (%) 10/12 (83.3) Disorientation, n/N (%) 7/12 (58.3) Seizures, n/N (%) 7/12 (58.3) Headache, n/N (%) 6/12 (50) Nausea and vomiting, n/N (%) 4/12 (33.3) Temperature, °C, median (range) 38.6 (37.2–39.5) Decreased level of consciousness, n/N (%) 7/12 (58.3) Neurological deficit, n/N (%) 3/12 (25) Abnormal CSF, n/N (%)† 12/12 (100) Leukocytes, /μL, median (range) 37 (0–150) Glucose, mg/dL, median (range) 76.3 (45.4–145.4) Protein, g/dL, median (range) 0.09 (0.05–0.2) Positive polymerase chain reaction for herpes simplex virus, n/N (%) 9/9 (100) Compatible cranial computed tomography at admission, n/N (%) 8/12 (66.7) Electroencephalogram Days, median (range) 1.3 (0–6) Positive, n/N (%) 9/10 (90) Magnetic resonance imaging Days, median (range) 8 (1–22) Compatible, n/N (%) 8/8 (100) Mean length of hospital stay, days, median (range) 38 (12–103) Main neurological sequelae, n/N (%) At discharge Memory disorders 4/12 (33.3) Behavioral changes 2/12 (16.6) Aphasia 2/12 (16.6) At 6 months Memory disorders 4/9 (44.4) Behavioral changes 2/9 (22.2) Aphasia 1/9 (11.1) * Only available in six of the nine patients alive (because of severe memory disorder in one patient, severa aphasia in one, and not available in the medical history in one). † Cerebrospinal fluid (CSF) leukocyte count was normal ( 40% of those recorded in blood; protein level ≥0.045 g/dL. This subgroup of elderly patients had characteristics similar to those found in other series, such as the predominance of temporal-frontal symptoms, disorientation, behavioral changes, and aphasia, reflecting the tropism for this anatomical level,2,8 but the mortality rate was higher than in the general population, in agreement with other studies that identified age as an independent prognostic factor.2–4,6 Main symptoms of neurological sequelae are neurological deficits such as aphasia, seizures, or other neuropsychological dysfunctions, especially memory disorders, which have been found to be common. Several studies have suggested that HSV-1 might be involved in the pathogenesis of Alzheimer's disease, being a susceptibility factor due to specific characteristics of the virus.9 Major symptoms observed in the current series, such as behavioral changes and disorientation, are common signs of many infectious diseases in older adults. Therefore, especially if not accompanied by seizures, many cases could be misdiagnosed as nonspecific infections, delaying the initiation of acyclovir. Because cranial CT in the emergency department has low sensitivity, if HSE is suspected, treatment with acyclovir should be started until PCR for HSV in CSF and MRI come back negative. In elderly patients with HSE, fever is usually present, and it may persist for some days, despite administration of acyclovir. HSE results in high morbidity and mortality, frequent ICU admission, and a long hospital stay. If HSE is suspected, treatment with acyclovir should not be delayed despite a normal CT. Because of the high prevalence of seizures, antiepileptic drugs, either for treatment or prophylaxis, should be used in these patients. ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Antoni Riera-Mestre, Ana Requena, and Sergio Martínez-Yélamos: letter design, data acquisition and interpretation, letter preparation. Carmen Cabellos: data interpretation, letter preparation. Pedro Fernández-Viladrich: critical revision of the letter. Sponsor's Role: None. REFERENCES 1 Whitley RJ, Roizman B. Herpes simplex virus infections. Lancet 2001; 247: 1513– 1518. 2 Tyler KL. Herpes simplex virus infections of the central nervous system: Encephalitis and meningitis, including Mollaret's. Herpes 2004; 11 (Suppl 2): 57– 64. 3 Koskiniemi M, Piiparinen H, Mannonen L et al. Herpes encephalitis is a disease of middle age and elderly people: Polymerase chain reaction for detection of herpes simplex virus in the CSF of 516 patients with encephalitis. The Study Group. J Neurol Neurosurg Psychiatry 1996; 60: 174– 178. 4 Hjalmarsson A, Blomqvist P, Sköldenberg B. Herpes simplex encephalitis in Sweden, 1990–2001: Incidence, morbidity, and mortality. Clin Infect Dis 2007; 45: 875– 880. 5 Jouanny P, Vespignani H, Gérard A et al. Herpetic meningoencephalitis in the elderly. Apropos of 13 cases. Rev Med Intern 1994; 15: 504– 509. 6 Riera-Mestre A, Gubieras L, Martínez-Yélamos S et al. Adult herpes simplex encephalitis: Fifteen years' experience. Enferm Infecc Microbiol Clin 2009; 27: 143– 147. 7 Van Swieten JC, Koudstaal PJ, Visser MC et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19: 604– 607. 8 Raschilas F, Wolff M, Delatour F et al. Outcome of and prognostic factors for herpes simplex encephalitis in adult patients: Results of a multicenter study. Clin Infect Dis 2002; 35: 254– 260. 9 Itzhaki RF, Wozniak MA. Herpes simplex virus type 1 in Alzheimer's disease: The enemy within. J Alzheimers Dis 2008; 13: 393– 405. Citing Literature Volume58, Issue1January 2010Pages 201-202 ReferencesRelatedInformation