Reactions 1680, p222 - 2 Dec 2017 Herpes simplex type 2 encephalitis: case report A 79-year-old man developed herpes simplex virus type-2 (HSV-2) encephalitis during treatment with methotrexate. The man, who had a history of peripheral spondyloarthritis (HLA-B27-positive), was receiving methotrexate 20 mg/week for two years [route not stated]. He was hospitalised for with a 4-day history of acute confusion, aphasia, fever and temporospatial disorientation. An EEG revealed slow wave activity. His CSF specimen showed protein level of 2.7 g/L, WBC count of 56 cells/mm (20% neutrophils and 80% lymphocytes) and glucose level of 4.2 mmol/L. The man was empirically treated with ceftriaxone, acyclovir and cotrimoxazole [sulfamethoxazole/trimethoprim]. Polymerase chain reaction (PCR) detected HSV-2 DNA in the CSF (HSV-2 load, 5.37 log10 copies/mL). Methotrexate and antibiotics were discontinued and acyclovir was continued. The PCR for Epstein-Barr virus (EBV) DNA was positive in the CSF with a viral load of 2.7 log10 copies/mL. The EBV serology showed a past infection and the possibility of EBV reactivation was considered. Two serum samples were taken at admission and two weeks later were retrospectively analysed with a commercially available HSV type-specific serological assay. Both of the serum samples examination were positive for HSV-2 IgG antibodies. On day 2, he went in coma (Glasgow Coma Score 8/15), but no abnormalities were observed on CT scan and EEG. He required sedation and mechanical ventilation support for six days. There was a significant improvement in his condition. An MRI of brain one month after the start of treatment showed abnormal signal hyperintensity on T2 imaging involving the right inferior temporal gyrus. One month after the onset of the encephalitis, he was discharged. A follow-up at six months after the discharge showed that he still experienced memory impairment and concentration disorders. His wife observed a change in personality in her husband, along with aggressive behaviour. Author comment: ’’In conclusion, although suspected, the role of lowdose [methotrexate] therapy as a risk factor of this rare case of HSV-2 encephalitis needs further evaluation.’’ Lupo J, et al. Herpes simplex type 2 encephalitis and methotrexate medication: A fortuitous or causative association in a patient with spondyloarthritis?. Antiviral Therapy 22: 357-359, No. 4, 2017. Available from: URL: http://doi.org/10.3851/ IMP3110 - France 803284285 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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