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Diagnosis of viral encephalitides: nonzoonotic-associated viruses.

Herpes Simplex Viruses (HSVs) HSVs are responsible for 10–20% of all cases of identifiable viral encephalitides in the United States (US). Although HSV-1 and -2 can cause encephalitis in neonates, almost all cases of HSV encephalitis in older children are the result of HSV-1 infection. In neonates, clinical findings include bulging fontanel, poor feeding, fever, temperature instability, irritability, lethargy and frequently seizures. Older children may have fever, altered level of consciousness, behavioral changes and focal neurologic deficits associated with temporal lobe involvement. Cerebrospinal fluid (CSF) analysis in the neonate generally demonstrates 100 white blood cells (WBC)/mm with a mononuclear predominance and elevated protein. The CSF profile in older children consists of a lymphocytic predominant pleocytosis of 10 –500 cells/mm. In some cases, the CSF may be hemorrhagic. Magnetic resonance imaging (MRI) is more sensitive than computed tomography (CT) for the detection of early brain changes that typically localize to temporal lobes. Electroencephalographic (EEG) examination reveals focal changes arising from the temporal lobes consisting of spike and slow-wave activity and periodic lateralized epileptiform discharges (PLEDs). HSV can be isolated from the CSF by culture in only 40% of neonatal HSV encephalitis cases and 2% of older children and adults with HSV encephalitis. Consequently detection of HSV DNA in the CSF using polymerase chain reaction (PCR) has become the test of choice for establishing the diagnosis of HSV encephalitis. Data from the Collaborative Antiviral Study Group found the sensitivity and specificity of PCR to be 94 and 98%, respectively, compared with brain biopsyconfirmed cases. Overall the sensitivity and specificity of PCR detection in cases of neonatal HSV encephalitis range from 75 to 100% and 71 to 100%, respectively. Based on other studies of PCR diagnosis of HSV encephalitis, the sensitivity of PCR in the diagnosis of nonneonatal HSV encephalitis is 97%. Detection of typespecific HSV antibodies in serum is possible; however, their utility in the diagnosis of HSV encephalitis is limited.