Herpes Simplex Virus Meningoencephalitis Following Pulse-Dose Methylprednisolone: A Case Report and Literature Review

Our plain-English summary of Herpes Simplex Virus Meningoencephalitis Following Pulse-Dose Methylprednisolone: A Case Report and Literature Review, by J. Horn, J.B. Mullholand, S. Ashraf, et al (The American Journal of Case Reports, 2021).

The study

• Authors: J. Horn, J.B. Mullholand, S. Ashraf, D. Shore, A. Van de Louw
• Journal: The American Journal of Case Reports
• Published: 2021;22:e933847
• Type of article: Case report, Review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND Several cases of herpes simplex virus type 1 meningoencephalitis (HSVE) have been reported in patients receiving steroids, but the exact contribution of steroids to the disorder remains unclear because other risk factors, such as chemotherapy, brain radiation, or surgery, were present in almost all cases. CASE REPORT We report the case of a 76-year-old man who developed HSVE following the administration of pulse-dose steroids. The patient had occupational asbestos exposure and a chronic interstitial lung disease of unclear etiology (sarcoidosis versus hypersensitivity pneumonitis) and was admitted for acute-on-chronic respiratory failure requiring mechanical ventilation. After a negative infectious workup and several days of antibiotics without improvement, pulse-dose steroids were administered. In the following days, the patient developed a fever and worsening encephalopathy. A lumbar puncture showed elevated nucleated cells and positive polymerase chain reaction for herpes simplex virus 1 in the cerebrospinal fluid, confirming the diagnosis of HSVE. Acyclovir treatment was initiated, but the patient later died as a result of persistent severe encephalopathy and respiratory failure with an inability to wean mechanical ventilation. CONCLUSIONS Clinicians should keep in mind that HSVE is a potential complication of steroids and carefully consider the benefit/risk ratio of pulse-dose steroids, taking into account associated factors of immunosuppression. A high level of awareness should be especially maintained in critically ill patients because of associated risk factors (critical illness immune paralysis) and because neurological signs of HSVE may be missed in mechanically ventilated, sedated patients.

In plain English

This article reported one patient with herpes simplex virus type 1 meningoencephalitis (HSVE, a brain infection) and reviewed published cases of herpes simplex meningoencephalitis associated with steroids, including both virus types. It was not a study of asbestos; the patient's occupational asbestos exposure appears only in his history. He was a 76-year-old man with long-term respiratory failure and an interstitial lung disease of unclear cause, suspected to be sarcoidosis or hypersensitivity pneumonitis. He was admitted with an acute worsening of respiratory failure and placed on a ventilator. After infection tests were negative, he received methylprednisolone, later increased to 1000 mg a day for 3 days. He then developed fever, a Candida bloodstream infection and worsening mental status, and his spinal fluid tested positive for HSV-1. He was treated with acyclovir but died on day 25. His lymphocyte counts stayed low throughout his intensive care stay. The autopsy ruled out sarcoidosis and hypersensitivity pneumonitis and found lung scarring most compatible with silicosis. The authors concluded that HSVE is a potential complication of steroids, but they stated that a causal link cannot be proven.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report of one patient, with a literature review that summarizes previously reported cases of steroid-associated herpes simplex virus meningoencephalitis (HSV-1, HSV-2 and unspecified type) in a table
• Who was studied: One 76-year-old man admitted with acute-on-chronic hypoxic respiratory failure. He had chronic interstitial lung disease of unclear cause, a significant smoking history and occupational asbestos exposure.
• Exposure: The exposure studied was steroids: methylprednisolone 46 mg/d started on day 5, increased on day 11 to 1000 mg/d for 3 days (pulse dose). Occupational asbestos exposure was part of the patient's history only. The article gives no fiber type and did not study it.
• Main results:
  • On day 13, after the steroids, the patient became febrile, and a blood culture grew Candida parapsilosis
  • On day 18 his mental status worsened. A lumbar puncture showed nucleated cells of 36 per microliter (92% neutrophils) in the cerebrospinal fluid.
  • Cerebrospinal fluid PCR was positive for HSV-1
  • The patient was treated with acyclovir but was transitioned to comfort care and died on day 25
  • The patient stayed lymphopenic throughout the ICU stay. His lymphocyte counts were consistently below 0.8 x 10^9 per liter, with a lowest value of 0.01 x 10^9 per liter, and his CD4 count was 66 per cubic millimeter.
  • The autopsy ruled out the sarcoidosis and hypersensitivity pneumonitis diagnoses that had been considered
  • At autopsy, the lung findings included interstitial fibrosis most compatible with silicosis
  • At autopsy, the neuropathology did not reveal any acute process
• The authors' conclusion: The authors concluded that clinicians should keep in mind that HSVE is a potential complication of steroids and should carefully weigh the benefits and risks of pulse-dose steroids in critically ill patients. They considered it likely that steroids played a key role in this patient, although a causal link could not be proven.
• Limitations the authors state:
  • The patient's lymphopenia on presentation was another potential risk factor for HSVE, which makes a causal link between steroids and HSVE difficult to assert
  • A causal link between steroids and HSVE in this patient cannot be proven

Topics

Medical terms in this study, explained in our Lexicon: Chemotherapy, Asbestos Exposure, Interstitial Lung Disease, Etiology, Pneumonitis.

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