Cakmak Celik Fatma, Dağdemir Ayhan, Eroğlu Cafer, Aydin Omer Faruk, Incesu Lütfi, Yilmaz Hava
Ondokuz Mayis Universitesi Tip Fakültesi, Cocuk Sağliği ve Hastaliklari Anabilim Dali, Samsun.
Mikrobiyol Bul. 2007 Oct;41(4):613-9. doi: 10.5578/mb.66921.
In spite of high rates of morbidity and mortality in herpes simplex virus (HSV) encephalitis, however, it is one of the exceptional viral infections with specific and effective therapy. In this report a HSV encephalitis case who was clinically unresponsive to acyclovir treatment, has been presented. An 11 months old girl patient has been brought to our clinic with the complaints of high fever and focal convulsions. Analysis of cerebrospinal fluid (CSF) revealed decreased glucose level and abundant red blood cells, despite it was not traumatic. The other CSF biochemical findings were found normal. Viral serology performed with CSF yielded negative result for HSV-1 IgG, positive result for HSV-2 IgG, and negative result for HSV-1/2 IgM, however, antibody index could not be estimated since it was not possible to obtain a simultaneous serum sample. Cranial magnetic resonance imaging (MRI) showed contrast material enhancement on bilateral temporal lobes. There was no growth in the CSF cultures. Acyclovir therapy (30mg/kg/day) was started with the prediagnosis of herpes encephalitis. In the third week of therapy CSF analysis was repeated because of the presence of partial paroxysmal attacts and absence of sufficient clinical improvement. In this CSF sample HSV-1 DNA was found positive by real-time polymerase chain reaction. Since CSF findings were still abnormal and the clinical picture worsened despite 21 days of therapy, the dose of acyclovir was increased to 60 mg/kg/day (3 weeks) with a possible drug resistance problem. Control brain MRI showed contrast enhancement on bilateral temporal lobes, with more intensivity in left, and encephalomalacia. Valproic acid and haloperidol were given to the patient for the treatment of permanent partial paroxysms and orofacial dyskinesis, developing in the follow-up period, respectively. After getting these complications under control, the patient was discharged and taken into follow-up. As a result, although it could not be possible to confirm the drug resistance by molecular methods, it was thought that this might be both a clinical and virological resistance phenomenon, because of the detection of HSV-DNA in the CSF sample during the period of severity of the illness.
尽管单纯疱疹病毒（HSV）脑炎的发病率和死亡率很高，但它是少数几种有特效治疗方法的病毒感染之一。在本报告中，介绍了1例对阿昔洛韦治疗无临床反应的HSV脑炎病例。一名11个月大的女童因高热和局灶性惊厥被带到我们的诊所。脑脊液（CSF）分析显示葡萄糖水平降低且红细胞丰富，尽管并非创伤性所致。其他脑脊液生化检查结果正常。脑脊液病毒血清学检测显示HSV-1 IgG为阴性，HSV-2 IgG为阳性，HSV-1/2 IgM为阴性，但由于无法同时采集血清样本，无法估算抗体指数。头颅磁共振成像（MRI）显示双侧颞叶有对比剂强化。脑脊液培养无细菌生长。在初步诊断为疱疹性脑炎后开始阿昔洛韦治疗（30mg/kg/天）。治疗第三周，由于仍有部分阵发性发作且临床改善不充分，故重复进行脑脊液分析。在该脑脊液样本中，实时聚合酶链反应检测发现HSV-1 DNA呈阳性。由于治疗21天后脑脊液检查结果仍异常且临床症状恶化，考虑可能存在耐药问题，将阿昔洛韦剂量增至60mg/kg/天（共3周）。对照脑MRI显示双侧颞叶有对比剂强化，左侧强化更明显，并有脑软化。在随访期间，分别给予丙戊酸和氟哌啶醇治疗患者出现的永久性部分性发作和口面部运动障碍。在控制这些并发症后，患者出院并接受随访。结果，尽管无法通过分子方法确认耐药性，但考虑到在疾病严重期脑脊液样本中检测到HSV-DNA，认为这可能是一种临床和病毒学耐药现象。
