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Chapter 4 : Herpes Simplex Encephalitis

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Abstract:

When confronted with a case of apparent sporadic encephalitis, most clinicians focus on the possibility of herpes simplex encephalitis (HSE). The evaluation will be expedited, and antiviral therapy will often be started promptly before the deterioration of consciousness. Herpes simplex virus (HSV) is one of a large group, the herpesviruses, that are characterized by their similar morphology, large DNA genomes, and tendency to persist in their natural hosts. The tegument surrounding the capsid consists of a bilayered membrane containing antigenic glycoproteins and lipid. Latent infection can be demonstrated by explantation of ganglion tissue and maintenance in tissue culture or by detection of HSV DNA by PCR. The immunoperoxidase technique is useful for demonstrating HSV antigens on sections of paraffin-embedded material or on smears. Occasional cases of acute encephalitis due to HSV-1 show atypical distribution of damage. The brain stem is the most common site of such atypical infection. It has long been recognized that the damage produced in HSE is largely confined to the limbic system, a group of structures that are closely linked anatomically and functionally. An alternative diagnosis was suggested in three HSV-negative patients—one abscess and two demyelinating disease including acute disseminated encephalomyelitis (ADEM). Modifications of treatment with acyclovir have evolved because of the continuing levels of mortality, residual morbidity, and recurrent illness.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Figures

Image of FIGURE 4.1
FIGURE 4.1

Appearance of undersurface of the brain in acute HSE. There are swelling, petechial hemorrhages, and necrosis of the temporal lobes, more marked on the right (left in picture).

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.2
FIGURE 4.2

Coronal slice across the brain from a case of acute HSE (14 days' duration) showing hemorrhage and swelling of the left temporal lobe and insula.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.3
FIGURE 4.3

Coronal slice across the brain from a case in which symptoms of HSE commenced 6 weeks before death. Liquefaction necrosis is evident in both temporal lobes, worse on the right than the left. The insula is affected bilaterally and the cingulate gyrus is affected on the right.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.4
FIGURE 4.4

Microscopic appearance in HSE of 5 days' duration. There is evidence of early inflammation and eosinophilic neurons containing nuclear inclusion bodies (arrows). Hematoxylin and eosin stain.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.5
FIGURE 4.5

Low-power view of the temporal lobe cortex in a case of HSE of 14 days' duration. Inflammation is seen in the meninges and cortex, and edema is prominent in layer 2 of the cortex. Hematoxylin and eosin stain.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.6
FIGURE 4.6

Cortical neurons intensely stained for HSV antigen in acute encephalitis. Counterstained with hematoxylin.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.7
FIGURE 4.7

Low-power view of temporal cortex in HSE (16 days' duration) showing heavy meningeal inflammatory infiltrate. Hematoxylin and eosin stain.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.8
FIGURE 4.8

Perivascular infiltrate in acute HSE (12 days' duration). A few lymphocytes and more frequent plasma cells and macrophages are present. Hematoxylin and eosin stain.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.9
FIGURE 4.9

Diagram of coronal brain slice showing sites of maximal demonstrable antigen (shaded) in HSE.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.10
FIGURE 4.10

Undersurface of the brain showing collapse and necrosis of the temporal lobes (the right being the most affected) (on left in figure) from a case of HSE (6 months' survival).

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.11
FIGURE 4.11

Electron micrograph of intranuclear herpes virions (arrows) from a biopsy of the temporal lobe in a case of HSE. Uranyl acetate and lead citrate stain; × 25,200.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.12
FIGURE 4.12

EEG of a 12-year-old with HSE and new onset of seizures and alteration of mental status. The patient was comatose and on mechanical ventilation at the time of study. EEG demonstrates slowing of background activity and periodic discharges with a frequency of 3 to 4 Hz in the right hemisphere. Courtesy of Huned Patwa, Yale University School of Medicine.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Image of FIGURE 4.13
FIGURE 4.13

MRI of HSE. Axial, T2-weighted image, demonstrating mesial temporal lobe hyperintensity on the left. Courtesy of Gordon Sze, Yale University School of Medicine.

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
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Tables

Generic image for table
TABLE 4.1

Types of acute sporadic encephalitis and location of discussion in this volume

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4
Generic image for table
TABLE 4.2

Neurological complications of HSV

Citation: Booss J, Esiri M. 2003. Herpes Simplex Encephalitis, p 41-60. In Viral Encephalitis in Humans. ASM Press, Washington, DC. doi: 10.1128/9781555817831.ch4

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