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 log
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 log
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
Reactions 2 Dec 2017 No. 16800114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved