673. Herpes Simplex Virus (HSV) Central Nervous (CNS) Infections: The Role of Acyclovir (ACV) Therapy
Session: Abstracts: Virology
Friday, October 22, 2010
Background:  

HSV2 CNS infection presents as aseptic meningitis (AM) while HSV1 causes an encephalitis (E).  Intravenous (IV) ACV has therapeutic benefits in the latter, but there are limited data on its role in  HSV2 meningitis.  We reviewed charts of 45 patients with AM or E, admitted to HCMC ( 2000- 2009 )with cerebrospinal fluid (CSF) positive for HSV by PCR.  

Methods:  Type specific HSV PCR results were performed using the Roche Lightcycler 2.0 ASR on 19 patient samples.

Results:  Patients’ mean age was 34.82 (SD 14.5) years.  31 (68.9%) were female; 10  (22.2%) had current or previous genital or oral herpes; and 13 (28.9%) had previous similar episodes.  13 ( 28.8%) had at least one underlying chronic illness.  ( HIV; DM; or other.) 8 patients had clinical and brain MRI evidence of E, 5 of whom had confirmed HSV1 infection. CSF WBC counts ranged from 1 to 825 cells, all had a lymphocytic preponderance with one exception (HSV 1 confirmed).

Outcomes and treatment regimens are as noted ( Table ); 37 (82.2%) were treated with ACV. The duration of treatment varied from 5 to greater than 21 days:  2 (4.4%) for less than 7 days; 13 (29%) for 7 days, 1(2%) for 10, and 9 (20%) for 14 days,  all of whom had complete neurologic recovery.  6 patients (13.2%) were treated for 21 days . 38 ( 84%) of the 45 patients with AM made a full recovery but only 2 of the 8 ( 25 %) patients, with E,  (4 of whom were treated with IV ACV for greater than 21 days), fully recovered.  E was associated with worse clinical outcomes (P = 0.001).

Table

Treatment

Number of patients

% with full neurologic recovery

Acyclovir IV only

  8 (17.8 % ) all with encephalitis

25%

Acyclovir oral only

 11 (24.4 %)

91%

Acyclovir Iv then oral

 18 (40 %)

100%

No therapy

    8 (17.8%)

100%

Conclusion:

Patients with HSV viral meningitic syndrome , particularly those with recurrent episodes, had a favorable outcome regardless of treatment.  Patients with an encephalitic syndrome had poorer outcomes despite prolonged IV ACV therapy. Limitations in the study include its observational nature, small size and lack of virologic subtype differentiation for some patients.The role and duration of ACV in HSV2 viral meningitis remains controversial; patients with recurrent disease who are not immunocompromised may be successfully treated symptomatically or with brief courses of PO ACV.


Subject Category: V. Virology including clinical and basic studies of viral infections, including hepatitis

Speakers:
Ramona Kyrillos, MD , Medicine, Hennepin County Medical Center, Minneapolis, MN

Disclosures:

R. Kyrillos, None

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