Unusual Manifestations of Herpes Simplex Infection: Chronic Meningitis and Pleural Effusion
Abstracts & Commentary
Synopsis: Herpes simplex virus is reported to have caused chronic meningitis in one patient and a pleural effusion in another.
Sources: Trudo FJ, et al. Pleural effusion due to herpes simplex type II infection in an immunocompromised host. Am J Respir Crit Care Med 1997;155:371-373; Chin RH, et al. Chronic meningitis due to herpes simplex virus in an immunocompetent host. Eur J Clin Microbiol Infect Dis 1996;15:650-653.
Trudo and colleagues reported the case of a 23-year-old woman with acute lymphocytic leukemia with prolonged chemotherapy-induced neutropenia who developed a left upper lobe infiltrate and hypoxemia as well as a left exudative pleural effusion. Cytologic examination of the pleural fluid revealed mesothelial cells containing Cowdry type-A intranuclear inclusions, and HSV type 2 grew in tissue culture. The infection cleared after treatment with acyclovir and resolution of neutropenia. The patient was found, after initiation of antiviral therapy, to have a single painless genital ulcer, but culture was negative.
Chin and colleagues reported the case of a 35-year-old woman with clinical and laboratory findings of meningitis that persisted for five weeks before resolution after treatment with acyclovir, which was instituted when PCR revealed the presence of herpes simplex virus (HSV). Cerbrospinal fluid, examined on several occasions, revealed abnormalities consistent with viral meningitis. The patient had no known immunocompromise. The PCR used could not distinguish herpes simplex types, but evidence suggested it was type 2.
COMMENT BY STAN DERESINSKI, MD, FACP
Approximately 10% of patients with primary genital HSV-2 infection have associated meningitis. In the immunocompetent patient, the meningitis, like the genital lesions, is self-limited. Some patients, however, develop recurrent meningitis, usually in association with recurrence of genital lesions. The duration of the meningitis may be up to seven days, particularly when associated with primary infection. It is uncertain whether antiviral therapy shortens the duration of meningeal symptoms.
The case of meningitis described here is distinctly unusual because of its duration. It is possible that the diagnosis was in error, but published results indicate that PCR is an excellent technique in the diagnosis of viral infections of the central nervous system (Jeffery KJM, et al. Lancet 1997;349:313-317). If others provide confirmatory evidence that HSV can cause prolonged meningitis, it may become necessary to include HSV infection in the differential diagnosis of such infections.
Similarly, only rare prior descriptions of pleural involvement by HSV infection have appeared in the literature. The diagnosis in this case appears unequivocal. Thus, HSV may also have to be considered in the differential diagnosis of exudative pleural effusion, at least in the immunocompromised host.
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