valacyclovir and Meningitis--Viral

Opportunistic viral infections are a well-recognized complication of anti-tumor necrosis factor (TNF) therapy for inflammatory bowel disease (IBD). Cases of severe or atypical varicella zoster virus infection, both primary and latent reactivation, have been described in association with immunosuppression of Crohn's disease (CD) patients. However, central nervous system varicella zoster virus infections have been rarely described, and there are no previous reports of varicella zoster virus meningitis associated with anti-TNF therapy among the CD population. Here, we present the case of a 40-year-old male with severe ileocecal-CD who developed a reactivation of dermatomal herpes zoster after treatment with prednisone and adalimumab. The reactivation presented as debilitating varicella zoster virus meningitis, which was not completely resolved despite aggressive antiviral therapy with prolonged intravenous acyclovir and subsequent oral valacyclovir. This is the first reported case of opportunistic central nervous system varicella zoster infection complicating anti-TNF therapy in the CD population. This paper also reviews the literature on varicella zoster virus infections of immunosuppressed IBD patients and the importance of vaccination prior to initiation of anti-TNF therapy.

Topics: Acyclovir; Adalimumab; Adrenal Cortex Hormones; Adult; Antibodies, Monoclonal, Humanized; Antiviral Agents; Crohn Disease; Herpes Zoster; Herpesvirus 3, Human; Humans; Immunocompromised Host; Immunosuppressive Agents; Male; Meningitis, Viral; Opportunistic Infections; Prednisone; Treatment Outcome; Tumor Necrosis Factor-alpha; Valacyclovir; Valine; Virus Activation

Herpes simplex virus type 2 (HSV-2) is a common cause of acute and recurrent aseptic meningitis. Our aim was to determine the impact of antiviral suppression on recurrence of meningitis and to delineate the full spectrum of neurological complications.. One hundred and one patients with acute primary or recurrent HSV-2 meningitis were assigned to placebo (n = 51) or 0.5 g of valacyclovir twice daily (n = 50) for 1 year after initial treatment with 1 g of valacyclovir 3 times daily for 1 week in a prospective, placebo-controlled, multicenter trial. The primary outcome was time until recurrence of meningitis. The patients were followed up for 2 years.. The first year, no significant difference was found between the valacyclovir and placebo groups. The second year, without study drugs, the risk of recurrence of verified and probable HSV-2 meningitis was significantly higher among patients exposed to valacyclovir (hazard ratio, 3.29 [95% confidence interval, 10.06-10.21]). One-third of the patients experienced 1-4 meningitis episodes during the study period. A considerable morbidity rate, comprising symptoms from the central, peripheral, and autonomous nervous system, was found in both groups.. Suppressive treatment with 0.5 g of valacyclovir twice daily was not shown to prohibit recurrent meningitis and cannot be recommended for this purpose after HSV meningitis in general. Protection against mucocutaneous lesions was observed, but the dosage was probably inappropriate for the prevention of HSV activation in the central nervous system. The higher frequency of meningitis, after cessation of active drug, could be interpreted as a rebound phenomenon.

Topics: Acyclovir; Adult; Antiviral Agents; Double-Blind Method; Female; Follow-Up Studies; Herpes Simplex; Herpesvirus 2, Human; Humans; Male; Meningitis, Viral; Prospective Studies; Secondary Prevention; Sweden; Treatment Outcome; Valacyclovir; Valine

To describe the clinical manifestations and treatment outcomes of patients with VZV meningitis and encephalitis consulting at two medical centers in Lebanon.. Retrospective study of patients with VZV meningitis and/or encephalitis confirmed by positive cerebrospinal fluid (CSF) VZV PCR.. Twenty patients were identified (13 males). The average age was 49.7±22.2 years. The most common complaint was headache (n=17/20). Common comorbidities included hypertension (n=7/20) and diabetes mellitus (n=5/20). Immunosuppression was reported in two patients. Vesicles were only observed in eight patients. Altered mental status, focal neurological deficits, and fever were documented in six, two, and four patients respectively. All patients had CSF leukocytosis with lymphocytic predominance, normal CSF/serum glucose ratio, and high CSF protein. Eighteen patients had brain CT scans showing no relevant findings. Two of 12 patients with brain MRI had focal abnormalities. Unilateral temporal slow waves were observed in three of four patients who underwent electroencephalograms. Four patients had encephalitis and 16 had meningitis. Eighteen patients received an antiviral therapy. Treatment either included intravenous acyclovir or oral valacyclovir. The encephalitis and meningitis groups had comparable mean duration of treatment (13.5±6.6 vs. 12.2±5.4, respectively). All admitted patients showed clinical cure with no reported neurological sequelae.. VZV infection should be suspected in any patient with signs and symptoms of viral meningitis or encephalitis, irrespective of age, immune status, presence or absence of vesicles, fever, or neck stiffness.

Topics: Acyclovir; Adult; Aged; Antiviral Agents; Cerebrospinal Fluid; Comorbidity; Electroencephalography; Encephalitis, Viral; Female; Herpesvirus 3, Human; Humans; Lebanon; Leukocytosis; Magnetic Resonance Imaging; Male; Meningitis, Viral; Middle Aged; Neuroimaging; Retrospective Studies; Tertiary Care Centers; Tomography, X-Ray Computed; Treatment Outcome; Valacyclovir; Varicella Zoster Virus Infection; Young Adult

Topics: Acyclovir; Adult; Encephalitis; Herpes Simplex; Herpesvirus 3, Human; Humans; Male; Meningitis, Viral; Meningoencephalitis; Simplexvirus; Valacyclovir; Valine; Varicella Zoster Virus Infection

Viral meningitis caused by varicella-zoster virus (VZV) is an uncommon neurological complication of herpes zoster. It may occur before or after the onset of the vesicular rash along the dermatomal distribution, which is the classic presentation of herpes zoster. We describe a case of a 51-year-old immunocompetent Caucasian man who presented with neck and severe right-sided facial pain. Eight days later, he had photophobia and papular rash on his forehead. Cerebrospinal fluid (CSF) examination confirmed aseptic meningitis and CSF PCR detected the presence of VZV DNA. Neurological complications of VZV infection, such as aseptic meningitis, may be difficult to diagnose and can cause delay in treatment, especially in cases with late onset of dermatological manifestations of herpes zoster. Definite diagnosis requires evidence of acute VZV infection in blood or cerebrospinal fluid.

Topics: Acyclovir; Antiviral Agents; Diagnosis, Differential; Exanthema; Herpes Zoster; Humans; Male; Meningitis, Viral; Middle Aged; Polymerase Chain Reaction; Valacyclovir; Valine

Herpes simplex virus 2 is a leading cause of viral meningitis and the most commonly recognized infectious cause of benign, recurrent meningitis. We report a retrospective, observational cohort study of patients with herpes simplex virus type 2 (HSV-2) meningitis, confirmed by polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF). The terms "herpes simplex," "meningitis," or "encephalitis" were searched in the medical records system of the Mayo Clinic in Rochester, Minnesota (1995-2008). Patients were included if they had a clinical diagnosis of meningitis and HSV-2 detected by PCR in the CSF. There were 28 patients with 33 episodes identified (83 % female; mean age at presentation of meningitis 36 years, range 17-53; mean time to HSV2 detection from symptom onset 3 days, range 0-6; history of genital herpes 23 %). No patient took oral antiviral treatment at the time of presentation. Episodes were most likely to include headache (100 %), photophobia (47 %), self-reported fever (45 %), meningismus (44 %), and nausea and/or vomiting (29 %). CSF at the time of meningitis was notable for elevated protein (mean 156 g/dL, range 60-258) and white cell count (mean 504 cells/μL, range 86-1,860) with normal glucose (mean 54 mg/dL, range 32-80). Mollaret cells were never detected. Neuroimaging was most often normal (83 %) when performed, although some cases showed nonspecific (14 %) or meningeal changes (3 %). There was no consistent relationship to genital herpes. The duration of treatment with intravenous acyclovir ranged from 3 to 14 days for the first meningitic episode (daily dose range from 500 to 1,000 mg and total dose range from 500 mg q8h for 3 days to 800 mg q8h for 14 days). For subsequent episodes, the duration of treatment of intravenous acyclovir ranged from less than 1 to 14 days (total dose range from 1,390 mg for 1 day to 900 mg q8h for 10 days). The dose of valacyclovir ranged from 500 mg once daily to 500 mg four times daily. The median duration of valacyclovir treatment following the first episode was 10 days (range 3 to 14 days, n = 13). The median duration of valacyclovir treatment following a subsequent meningitic episode was 9 days (range 7 days to indefinite period, n = 9). No patient was reported to have seizures, neurological disability, or death in extended follow-up (mean follow-up 3.4 years). Recurrence of meningitic symptoms was not universal.

Topics: Acyclovir; Adolescent; Adult; Antiviral Agents; Drug Administration Schedule; Female; Herpes Simplex; Herpesvirus 2, Human; Humans; Male; Meningitis, Viral; Middle Aged; Retrospective Studies; Secondary Prevention; Treatment Outcome; Valacyclovir; Valine

Topics: Acyclovir; Anti-Bacterial Agents; Antiviral Agents; Aspirin; Diagnosis, Differential; Female; Headache; Humans; Meningitis, Viral; Middle Aged; Photophobia; Recurrence; Spinal Puncture; Valacyclovir; Valine

Topics: Acyclovir; Adult; Antiviral Agents; Female; Humans; Meningitis, Viral; Recurrence; Simplexvirus; Valacyclovir; Valine

Two cases of varicella zoster virus (VZV) meningitis are described in an 18-year-old girl and an 18-year-old boy. They occurred, respectively, 9 days and 9 months after allogeneic bone marrow transplantation. VZV nucleic acid was detected in the cerebrospinal fluid during the 1st week of illness. This recurrence occurred despite valaciclovir prophylaxis and without skin lesions. The two patients received aciclovir intravenously and immunoglobulins infusion. They responded to treatment and their clinical state improved rapidly.

Topics: Acyclovir; Adolescent; Antiviral Agents; Bone Marrow Transplantation; Cerebrospinal Fluid; Chemoprevention; Chickenpox; Female; Herpes Zoster; Herpesvirus 3, Human; Humans; Male; Meningitis, Viral; Valacyclovir; Valine

Recurrent benign lymphocytic meningitis is a recurring, typically innocuous, painful form of aseptic meningitis. This syndrome is associated with transient neurological symptoms in one-half of afflicted patients. The causative agent is usually herpes simplex virus type 2, which can be confirmed by detection of viral DNA in the cerebrospinal fluid using polymerase chain reaction. Clinical disease resolves spontaneously; however, acyclovir, valacyclovir, and famciclovir have been administered to some patients for both episodic therapy and suppression of recurrences. This therapy is thought to be beneficial, although there is no controlled trial data to support efficacy and safety.

Topics: 2-Aminopurine; Acyclovir; Adult; Aged; Antiviral Agents; Famciclovir; Female; Herpesvirus 2, Human; Humans; Male; Meningitis, Viral; Middle Aged; Recurrence; Valacyclovir; Valine

It is well known that herpes simplex virus (HSV) type 2 produces acute meningitis, while HSV type 2 rarely causes recurrent meningitis (Mollaret's meningitis). We report the history of a 40-year-old patient with recurrent HSV type 2 meningitis (Mollaret's meningitis). The patient had seven episodes of meningeal symptoms within a 7-year period. In the seventh episode, HSV type 2 DNA was confirmed by nested polymerase chain reaction (PCR) with the cerebrospinal fluid (CSF). A real-time quantitative PCR study of the first CSF sample detected 2,000 copies of the HSV genome, which rapidly disappeared following treatment with acyclovir. The present case may be the first case of HSV type 2 Mollaret's meningitis to be documented in Japan. In our case, HSV serum antibody titers were at low levels during the whole course of the disease. The possible pathophysiology of this case is discussed.

Topics: Acyclovir; Adult; Antiviral Agents; Herpes Genitalis; Herpesvirus 2, Human; Humans; Japan; Male; Meningitis, Viral; Polymerase Chain Reaction; Recurrence; Time Factors; Valacyclovir; Valine