Clinical resistance to antiviral drugs requies that a virus evade drug therapy yet retain pathogenicity. Thymidine kinase (TK)-negative mutants ofherpes simplex virus are resistant to the drug, acyclovir, but are attenuated for pathogenicity in animal models. However, numerous cases of clinical resistance to acyclovir have been associated with viruses that were reported to express no TK activity. We studied an acyclovir-resistant clinical mutant that contains a single-base insertion in its tk gene, predicting the synthesis of a truncated TK polypeptide with no TK activity. Nevertheless, the mutant retained some TK activity and the ability to reactivate from latent infections of mouse trigeminal ganglia. The mutant expressed both the predicted truncated polypeptide and a low level of a polypeptide that comigrated with full-length TK on polyacrylamide gels and reacted with anti-TK antiserum, providing evidence for a frameshifting mechanism. In vitro transcription and tanslation ofmutant tkgenes, incuding constructs in which reporter epitopes could be expressed only if frameshiffing occurred, also gave rise to truncated and full-length polypeptides. Reverse transcriptase-polymerase chain reaction analysis coupled with open reading fram cloning failed to detect alterations in tktrspts that could account for the synthesis offull-length polypeptide. Thus, synthesis of full-length TK was due to an unusual net +1 frmeshlft during translation, a phenomenon hitherto confined in eukaryotic cells to certain RNA viruses and retrotransposons. Utilization of cellular frameshifting mechanisms may permit an otherwise TK-negative virus to exhibit clinical acyclovir resistance.Herpes simplex virus (HSV) is an important human pathogen, especially in patients with AIDS. A major advance in antiviral therapy has been the use of acyclovir to treat HSV infections, but acyclovir resistance is a problem of increasing clinical significance in immunocompromised patients (1). Clinical resistance implies that HSV can mutate to evade drug therapy yet retain pathogenicity. Because the sensitivity of HSV to acyclovir is due largely to the viral thymidine kinase (TK), which activates the drug (2), HSV tk mutations can confer acyclovir resistance (3). Indeed, there have been numerous cases ofpatients who suffered severe HSV disease despite acyclovir therapy and shed acyclovir-resistant viruses that were reported to express no detectable TK activity and/or full-length TK polypeptides (4-13).Although TK is not essential for viral replication in cell culture, it is important for viral pathogenesis in animal models. In particular, TK-mutants fail to reactivate from latent infections of mouse sensory ganglia (14-16), due to the tk mutation (16). Thus, the association of virus that appears TK-with severe HSV disease has been puzzling. One possible resolution of this paradox is that the clinical isolates expressed low levels of TK that were not detected. There are HSV mutants that are severely impaired for TK activity and thus acyclovir-resistant...