In the Journals

Immunocompromised patients with HSV meningitis may benefit from antiviral therapy

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October 28, 2014

While immunocompetent patients with herpes simplex virus meningitis can be successfully managed with symptomatic treatment alone, immunocompromised patients also may require antiviral therapy to prevent chronic neurocognitive deficits, according to recent findings.

“While there are excellent studies underscoring the importance of IV acyclovir therapy in reducing both mortality and morbidity in patients with HSV encephalitis, the role of antiviral treatment for HSV meningitis remains unclear,” researchers wrote in Clinical Infectious Diseases.

In a retrospective observational study, the researchers evaluated 53 patients seen at Hennepin County Medical Center, Minneapolis, between July 2000 and November 2012. All case-patients had cerebrospinal fluid (CSF) specimens positive for HSV 1 or 2 by PCR assay. Electronic Health Record data were collected for all patients. Neurologic outcomes were defined in terms of complete neurocognitive recovery, partial recovery or residual neurocognitive deficiencies.

Chronic neurocognitive deficits were defined as: chronic headaches, focal weakness, paresthesia or sensory problems, ongoing confusion, short- or long-term memory deficiencies, instability of gait, speech impairment, executive function impairment, or seizures.

The researchers found that 42 patient-episodes were clinically diagnosed as meningitis. No antiviral medication was administered to six of these patient-episodes. The rest of the patients were assigned either oral antiviral treatment (n=11), combination IV and oral antivirals (n=22) or IV acyclovir monotherapy (n=3). Six patients had recurrent meningitis, but all patients recovered without neurologic sequelae. Immunocompromised patients with HSV meningitis had improved neurologic outcomes with antiviral therapy (P<.05). Antiviral therapy did not yield improvements in the 27 patient-episodes among immunocompetent patients (P=1), as this group did not demonstrate any neurologic sequelae.

According to the researchers, these findings may be useful in guiding treatment for patients with HSV meningitis.

“Based on our analysis, we recommend treating immunocompromised patients with HSV meningitis with a 7- to 10-day course of specific antiviral therapy to improve neurologic outcomes,” the researchers wrote. “The emphasis of therapy in acutely ill immunocompetent patients with the HSV meningitis should be on rehydration and analgesia rather than IV acyclovir therapy, with its attendant risks.”

Disclosure: The researchers report no relevant financial disclosures.

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