Journal of Pediatric Ophthalmology and Strabismus

Systemic and Topical Use of Poly I.C. in Treatment of Generalized Neonatal Herpes Simplex Infection with Severe Ocular Involvement

A Romano, MD; C Kaplinsky, MD; M Frand, MD; Y Rotem, MD; R Stein, MD; M Blumenthal, MD

Abstract

A case of Neonatal Herpes Simplex virus (HSV) encephalitis with severe ocular manifestation, treated by topical, systemic and intrathecal Interferon inducer - Poly IC (Polyriboinosinic acid-Polyribocytidylic acid) - is reported. The clinical course, the mechanism of action of Interferon, and the facts known in literature on the subject are dealt with in detail.

CASE REPORT

A three- week-old female infant was born to nonrelated parents after an uneventful pregnancy and normal vaginal delivery. Birth weight was 2400 gr. After birth, she made good progress and gained weight. Four days before admission, she became pyrexic, extremely excited, and anorexic. One day prior to admission, right-sided convulsions began which slowly progressed to all of the trunk. On examination, there were no gross findings apart from generalized bilateral tonic and clonic seizures with marked motor irritability and hyperexcitability. In the right corner of the upper lip, there was a solitary yellowish vesicle. The anterior fontanelle was normotensive. Ophthalmic examination was within normal limits. Lumbar puncture yielded clear fluid under normal pressure, with up to 80 lymphocytes/mm\ with normal levels of glucose and chlorides, and total protein levels of 400 mg/dl. Blood and CSF cultures did not grow bacteria. PPD skin test was normal. Treatment with intravenous ampicillin (200 mg/kg) and garamycin (6 mg/kg) was initiated. Administration of Diazepam (5 mg IV in repeated doses), phénobarbital (30 mg/day)and chloral hydrate20 ml of 10% solution thrice daily) failed to stop seizures. Severe respiratory distress followed by respiratory arrest required intubation and mechanical ventilation. On the third hospital day multiple vesicles erupted on the face in the typical location and having the typical appearance of primary neonatal occular HSV infection (Fig. 1 ). There was a bilateral moderate injection of bulbar and palpebral conjunctivae with serosanguineous discharge but without corneal involvement.

Samples of blood, csf and fluid from the cutaneous vesicles were taken for virological, bacteriological and serological examination. At that stage we reexamined the parents for the presence of genital HSV infection, which was confirmed by them and by clinical examination.

In view of the positive history of active genital herpetic infection in both parents, and the typical cutaneous eruption on the infant's face, neonatal HSV encephalitis was diagnosed.

Intravenous and topical treatment with Poly IC was begun. An initiating IV dose of 1000 Y/ml in a bolus injection was followed by 2000 Y/day for seven successive days. A total of 600 Y Poly IC daily was applied topically on the vesicles and in the conjunctival sacs, four times a day for seven days. On the fifth day of Poly IC treatment, 100 Y was injected intrathecally followed by 200 Y for another two days. During this course of treatment, daily samples of blood, CSF and vesicular fluid were taken for virus isolation serologic work up and Interferon level measurements. Daily liver function tests and blood counts were also performed. Slight clinical improvement in vital functions followed, body temperature dropped, and mechanical ventilation was not required. The infant was still semicomatose, nonreactive to painful stimuli and continued to suffer from sporadic convulsions for short periods. An EEG tracing showed complete flattening of cortical activity and disappearance of rhythmic activity. Contrast air studies were compatible with obstructive hydrocephalus and porencephaly. On repeated ophthalmic examination, bilateral chorioretinitis was present. The retina showed large patches of massive yellowish-white exudates in the posterior pole. The infant remained in vegetative state for three months and died of terminal bronchopneumonia and sepsis.

Among the stimulating factors mentioned above, the most extensively investigated in mankind is a synthetic polymer, Poly IC.

This is practically a double stranded RNA molecule with a potent…

A case of Neonatal Herpes Simplex virus (HSV) encephalitis with severe ocular manifestation, treated by topical, systemic and intrathecal Interferon inducer - Poly IC (Polyriboinosinic acid-Polyribocytidylic acid) - is reported. The clinical course, the mechanism of action of Interferon, and the facts known in literature on the subject are dealt with in detail.

CASE REPORT

A three- week-old female infant was born to nonrelated parents after an uneventful pregnancy and normal vaginal delivery. Birth weight was 2400 gr. After birth, she made good progress and gained weight. Four days before admission, she became pyrexic, extremely excited, and anorexic. One day prior to admission, right-sided convulsions began which slowly progressed to all of the trunk. On examination, there were no gross findings apart from generalized bilateral tonic and clonic seizures with marked motor irritability and hyperexcitability. In the right corner of the upper lip, there was a solitary yellowish vesicle. The anterior fontanelle was normotensive. Ophthalmic examination was within normal limits. Lumbar puncture yielded clear fluid under normal pressure, with up to 80 lymphocytes/mm\ with normal levels of glucose and chlorides, and total protein levels of 400 mg/dl. Blood and CSF cultures did not grow bacteria. PPD skin test was normal. Treatment with intravenous ampicillin (200 mg/kg) and garamycin (6 mg/kg) was initiated. Administration of Diazepam (5 mg IV in repeated doses), phénobarbital (30 mg/day)and chloral hydrate20 ml of 10% solution thrice daily) failed to stop seizures. Severe respiratory distress followed by respiratory arrest required intubation and mechanical ventilation. On the third hospital day multiple vesicles erupted on the face in the typical location and having the typical appearance of primary neonatal occular HSV infection (Fig. 1 ). There was a bilateral moderate injection of bulbar and palpebral conjunctivae with serosanguineous discharge but without corneal involvement.

Samples of blood, csf and fluid from the cutaneous vesicles were taken for virological, bacteriological and serological examination. At that stage we reexamined the parents for the presence of genital HSV infection, which was confirmed by them and by clinical examination.

In view of the positive history of active genital herpetic infection in both parents, and the typical cutaneous eruption on the infant's face, neonatal HSV encephalitis was diagnosed.

Intravenous and topical treatment with Poly IC was begun. An initiating IV dose of 1000 Y/ml in a bolus injection was followed by 2000 Y/day for seven successive days. A total of 600 Y Poly IC daily was applied topically on the vesicles and in the conjunctival sacs, four times a day for seven days. On the fifth day of Poly IC treatment, 100 Y was injected intrathecally followed by 200 Y for another two days. During this course of treatment, daily samples of blood, CSF and vesicular fluid were taken for virus isolation serologic work up and Interferon level measurements. Daily liver function tests and blood counts were also performed. Slight clinical improvement in vital functions followed, body temperature dropped, and mechanical ventilation was not required. The infant was still semicomatose, nonreactive to painful stimuli and continued to suffer from sporadic convulsions for short periods. An EEG tracing showed complete flattening of cortical activity and disappearance of rhythmic activity. Contrast air studies were compatible with obstructive hydrocephalus and porencephaly. On repeated ophthalmic examination, bilateral chorioretinitis was present. The retina showed large patches of massive yellowish-white exudates in the posterior pole. The infant remained in vegetative state for three months and died of terminal bronchopneumonia and sepsis.

Fig. 1. The infant showing development of herpetic skin lesions and vesicles near the lid margins.

Fig. 1. The infant showing development of herpetic skin lesions and vesicles near the lid margins.

Table

TABLE IISOLATION OF HERPES SIMPLES VIRUS AT TIME OF POLY IC TREATMENT IN THE CASE OF NEONATAL GENERALIZED HSV INFECTION

TABLE I

ISOLATION OF HERPES SIMPLES VIRUS AT TIME OF POLY IC TREATMENT IN THE CASE OF NEONATAL GENERALIZED HSV INFECTION

Laboratory Data: Virus Isolation

The vesicular fluid and tears were cultured for HSV by rolling cotton swab over the surface lesions and the conjunctiva of the lower fornix of the eye. The swabs were immediately placed into vials containing 1.5 ml medium 199 (1% calf serum and antibiotics). The samples were inoculated into tubes of monolayer culture of Rabbit Kidney primary cells, which were examined for cytopathogenic effect daily.

Serum Neutralizing Antibody Titer

The neutralizing antibody titer was assayed by inhibition of the cytopathogenic effect in Vero ceils using a standard type 2 virus.' Fluorescent antibody studies were performed using the F.A. Technique of Chien Liu2 according to the indirect method of identification.

RESULTS

The laboratory results are summarized in Table I and Table II. No virus could be isolated from the cutaneous lesions and conjunctival sac after three days of Poly IC treatment.

Rising levels of antibodiesto Herpes Simplex using the CFT method were found in the blood. These levels. were from 1:30 to 1:60 during the illness.

Antibodies to Herpes in CSF were found on the first day and remained constant throughout the patient's illness.

Table

TABLE IILABORATORY RESULTS

TABLE II

LABORATORY RESULTS

Interferon Levels were measured in the blood, CSF, and tears during Poly IC treatment. Before administration of Poly IC Interferon could not be detected in the blood and CSF, but 24 hours after IV injection, there was a measureable level (1:8-1:32) in the blood, which remained constantduring the treatment. It is worth mentioning that IV treatment in the dosage scheduled in Table II did not initiate Interferon presence in CSF. Intrathecal administration of Poly IC induced a significant rise in Interferon levels in the CSF.

Pathological Findings

The pathological findings in the brain were compatible with massive destruction of normal tissue, with diffuse and focal gliosis perivascular mononuclear infiltration, which also spread to the meninges. Many calcified inclusion bodies were seen (Fig. 2).

DISCUSSION

Herpes virus hominis known also as Herpes Simplex Virus is a common cause of fatal encephalitis in adults and neonates. Its two stereotypes are completely different in their clinical and pathologic manifestations.'

Type I in adults causes lesions in the mouth, cornea, skin, and central nervous system (CNS). Type II is transmitted exclusively by genital contact, and usually causes only genital and cutaneous lesions, but may cause a diffuse disease. 4"h Many reports of ocular involvement such as conjunctivitis, chorioretinitis, uveitis, and also encephalitis in neonates with disseminated HSV infection have recently been reported.7"

The incidence of congenital infection has not been established, but some believe it to be about one case to 7500 live-births. I>u About 80 percent of the genital infections are caused by HSV type II. 14,15

The clinical course of neonatal HSVencephalitis is very similar in the majority of the reports. It usually begins with pyrexia, convulsions, deteriorating consciousness, and depression of vital centers.

The diagnosis usually is made late in the course of the disease, after failure of bacteriologie and biochemical work upto define the etiology. Only by specific virologie and serologic laboratory procedures and a high index of suspicion may the viral etiology be proved.

Brain biopsy has been the most accepted approach for viral identification and isolation. 15 Recently, more rapid and accurate methods for viral identification have been utilized. These methods include complement-fixation test (CFT) to HSV,: neutralization test,' and immunofluorescent.u'~w

According to the literature there are three therapeutic possibilities: (1) administration of IDU (5 IOD 2-Deoxyuridine); (2) administration of Cytosin-Arabinoside; and (3) use of interferon. IDU is an antimetabolite, which acts as a competitive inhibitor to Thymidine uptake into the RNA molecule.2" Since it was introduced into clinical trial good results had been achieved in the treatment of topical herpetic keratitis and mucco-cutaneous lesions."' Many side effects have been observed on systemic administration of the drug, such as stomatitis, alopecia, and severe bone marrow depression."

The established concept in the past years has been to avoid the use of IDU because of the bone marrow cytotoxicity.'3"25

Cytosine Arabinoside was not used because of the known cytotoxic effects in this very you ng age, and also because we realized that the drug would not penetrate the blood-brain barrier.26

A new approach in antiviral therapy has emerged following the discovery of interferon by Lindeman and Isaacs."7 They found that this protein with a molecular weight of 20,000 is produced in reaction to viral infection or nonviral factors, and acts by preventing the replication of DNA molecule and inhibiting the action of DNA. Interferon is synthesized in any cellular tissue, after being induced by viruses specific group of double-stranded RNA molecules, endotoxins, gram-negative bacteria and mitogens such as phytohemagglutinins and streptolysin. 2*~w The lymphocytes are considered the major site for interferon production, and this characteristic is constant beginning in fetal life and in the postnatal period.1'"12

Two mechanisms are considered responsible for Interferon induction: (1) synthesis of Interferon de novo by each cellular tissue in reaction to various stimuli as described; (2) release of Interferon stored in the reticuloendothelial system. The inactive form is activated during its release from RES cells.28

The disadvantage of endogenous Interferon is its ultrashort action and the persistance of very low serum concentration. Positive "defending" effect is achieved when Interferon is administered close to the infection.29'10'"

Fig. 2. Pathological findings in the brain: (a) Massive destruction of normal tissue: (b) Focal gliosis: and (c) Calcified inclusion bodies. Paraffin sections, H and E stains, photomicrographs.

Fig. 2. Pathological findings in the brain: (a) Massive destruction of normal tissue: (b) Focal gliosis: and (c) Calcified inclusion bodies. Paraffin sections, H and E stains, photomicrographs.

Among the stimulating factors mentioned above, the most extensively investigated in mankind is a synthetic polymer, Poly IC.

This is practically a double stranded RNA molecule with a potent Interferon-induction ability." This preparation is very effective against various viruses as was proved in animal and human experimentation."

The conclusions drawn from experimentation with Poly IC in animals are: (1) there is a defending effect of the drug if administered before or even after the infection occurred36"37; (2) the levels of induced Interferon are linearly dependant on the dosage of the drug, route, a nd frequency of administration36'3"; and (3) there were no hepatic or hematologic complications in human trials.

De Clerque et al39 were the first to report intrathecal injection of Interferon to an infant suffering from herpetic meningo-encephalitis. They found high titers of Interferon in the CSF, but failed to show any clinical improvement. It is worth mentioning that they began their treatment on the 20th day of the infant's illness. In view of the conclusions above, it seems that the results could have been improved if Interferon had been injected much earlier and close to the onset of the disease.

Our considerations favoring administration of local and systemic Poly IC to the infant presented were based on the following criteria:

1 . Purified human Interferon is not commercially available, is expensive and must be repetitively injected because of it's ultrashort action.

2. We have accumulated a clinical experience with Poly IC administered topically and systemically to 61 patients with severe Herpetic Dentritic Keratitis and Iritis, who completely recovered, without evident side effects of the drug.21

3. We were aware of the side effects of the other mentioned antiviral drugs.

4. The commercially available Poly IC used by us has been proved to be purified, nonpyrogenic, nontoxic in animal experimentations, and highly effective as an Interferon inducer.

Analysis of our clinical results show that:

1 . Virus Clearance from the conjunctiva and cutaneous lesions was remarkably rapid under topical and systemic Poly IC treatment, as previously reported.21

2. Intravenous Poly IC injection did not cause a rising titer of Interferon in CSF as expected in experimental models.""35 A significant rise of Interferon levels in cerebrospinal fluid was evident, on the other hand, after intrathecal injection of Poly IC.

3. There was a mild clinical improvement in the infant's general condition and vital functions, and possibly some alterations in the EEG tracings.

4. There was no defencing effect on the deteriorating cortical degeneration, and progressive hydrocephalus. This supports the basic concept that "defending" effect is achieved when Poly IC or Interferon are administered very shortly after infection has occurred.

For these reasons we believe that Poly IC should be given to any suspected or proved case of viral encephalitis, as soon as suspicion is raised in order to prevent irreversible neuronal damage. In order to initiate rapid rise of Interferon in the CSF, we believe that Poly IC should be injected intrathecally.

We believe that more therapeutic experience must be accumulated in order to define the optimal dosage and adequate period of therapy.

SUMMARY

A case of Neonatal Herpes Simplex Virus (RSV) Encephalitis with severe ocular manifestation treated by topical systemic and intrathecal Interferon inducer. Poly IC (Polyriboinosinic acid-Polyribocytidylic acid) is reported. Prior to the administration of Poly IC, no Interferon could be detected neither in blood nor in CSF and vesicular fluid from conjunctiva. Intravenous administration of the drug initiated measurable levels in blood and tears, but not in CSF. However, intrathecal injection induced persistent high levels of Interferon in CSF. Virus clearance from conjunctiva tears and vesicular fluid occurred after three days of topical application of Poly IC.

The mechanism of action of Poly IC, the laboratory results and the therapeutic conclusions are discussed in detail. This is the first report of intrathecal administration of Poly IC in a case of HSV Encephalitis.

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TABLE I

ISOLATION OF HERPES SIMPLES VIRUS AT TIME OF POLY IC TREATMENT IN THE CASE OF NEONATAL GENERALIZED HSV INFECTION

TABLE II

LABORATORY RESULTS

10.3928/0191-3913-19780701-13

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