The Role of Antiviral Therapy in Immunocompromised Patients With Herpes Simplex Virus Meningitis

Abstract

Most patients with HSV meningitis rapidly improve, but immunocompromised hosts have more neurologic sequelae and may benefit from antiviral therapy. Our data suggest symptomatic treatment alone for immunocompetent patients with HSV meningitis, avoiding the cost and side effects of prolonged intravenous acyclovir therapy; in contrast, immunocompromised patients had improved outcomes and would therefore benefit from antiviral therapy.

HSV-2 meningoencephalitis in an immunocompetent young man: what is the pathogenesis and what is the treatment?

“…Although no randomized controlled trials in HSV-2 meningitis have been performed in the acute stage, several authors favored symptomatic therapy, since no neurological sequelae were noted even in patients experiencing recurring episodes of meningitis [6,24]. In contrast, in HSV-1 encephalitis, a poor outcome was significantly correlated with a delay of aciclovir therapy >2 days after hospital admission [8], and future studies will be necessary to establish the interest of helicase primase inhibitors in treating CNS HSV disease [25].…”

Meningitis in adults: diagnosis and management

“…35 CSF lactate is not proportional to serum lactate, but it may be elevated in central nervous system (CNS) conditions other than bacterial meningitis, such as viral encephalitis or seizures. 39,40 HIV is an important yet overlooked cause of viral meningitis. 36 PCT is particularly helpful in the diagnosis of early bacterial meningitis as it becomes detectable within 3-4 h of onset of symptoms, compared with the 12-24 h that CRP takes to rise.…”

“…39 It is vital to recognise that HSV encephalitis (usually caused by HSV-1) is a distinct entity from HSV meningitis (usually caused by HSV-2); in HSV encephalitis, treatment with IV acyclovir is critical in reducing mortality and disability. Enteroviral meningitis is self-limiting and requires only supportive care.…”

“…35,36,38 Aseptic meningitis: not synonymous with viral meningitis Viral meningitis is most commonly caused by the enteroviruses and is self-limiting, although HSV or VZV meningitis may warrant antiviral therapy in some circumstances. 39,40 HIV is an important yet overlooked cause of viral meningitis. The yield of testing for HIV was shown in one report from North Carolina where stored CSF samples from 57 patients who had presented with non-bacterial meningitis were retrospectively tested for HIV RNA.…”

“…HSV meningitis is also self-limiting in immunocompetent patients; symptomatic treatment alone is reasonable, although 7-10 days of antiviral treatment (with acyclovir, valacyclovir or famciclovir) has been shown to improve neurological outcomes in immunocompromised hosts. 39 It is vital to recognise that HSV encephalitis (usually caused by HSV-1) is a distinct entity from HSV meningitis (usually caused by HSV-2); in HSV encephalitis, treatment with IV acyclovir is critical in reducing mortality and disability. 40 The optimal treatment of VZV meningitis is unknown, although most clinicians would give antivirals unless the patient was already improving without therapy.…”