Symptomatic central nervous system tuberculosis and human herpesvirus-6 coinfection with associated hydrocephalus managed with endoscopic third ventriculostomy: A case report and review of human herpesvirus-6 neuropathology.

Surgical neurology international Pub Date : 2024-08-16 eCollection Date: 2024-01-01 DOI:10.25259/SNI_355_2024
Nicholas Edward Bui, Paras Savla, Alvaro E Galvis, Brian William Hanak
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Abstract

Background: Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus well established in the clinical literature to cause the near-universal childhood infection roseola infantum (exanthema subitum/sixth disease). Primary HHV-6 infection has been reported to cause meningoencephalitis in pediatric patients, although generally in the immunocompromised.

Case description: The authors treated an immunocompetent 18-month-old female who transferred to our institution for a higher level of care given concerns for meningitis in the setting of decreased level of arousal (Glasgow Coma Scale 12), and bradycardia 9 days after the onset of nasal congestion, fatigue, and repeated bouts of emesis. Outside hospital cerebrospinal fluid (CSF) studies were notable for hypoglycorrhachia, elevated protein, elevated nucleated cells with a mononuclear predominance, and a meningitis polymerase chain reaction panel that was positive only for HHV-6. Brain magnetic resonance imaging with and without contrast revealed a basal cistern predominant leptomeningeal enhancement pattern as well as moderate ventriculomegaly with associated periventricular edema concerning acute communicating hydrocephalus. Considering the CSF studies, neuroimaging, and recent travel history to Mexico, central nervous system (CNS) tuberculosis (TB) was the leading suspicion, and antimicrobial therapy was initiated for this presumptive diagnosis with culture data only proving the TB suspicion correct after nearly 2 months in culture. Anti-viral therapy was initially not felt to be necessary as the HHV-6 was interpreted as incidental and not a cause of symptomatic meningitis in our immunocompetent host. The patient's hydrocephalus was treated with temporary CSF diversion followed by performance of an endoscopic third ventriculostomy. Despite appropriate hydrocephalus management, clinical improvement ultimately seemed to correlate with the initiation of antiviral therapy.

Conclusion: The authors present this case and review the literature on HHV-6-associated CNS infections with the goal of informing the neurosurgeon about this often clinically underestimated pathogen.

有症状的中枢神经系统结核和人类疱疹病毒-6合并感染,并伴有脑积水,经内窥镜第三脑室造口术治疗:病例报告和人类疱疹病毒-6神经病理学回顾。
背景:人类疱疹病毒 6(HHV-6)是一种双链 DNA 病毒,在临床文献中已被证实可引起几乎普遍的儿童玫瑰疹婴儿病(皮下红斑/第六病)。有报道称,原发性 HHV-6 感染可导致儿科患者发生脑膜脑炎,但通常是在免疫力低下的人群中发生:作者收治了一名免疫功能正常的 18 个月大的女性患者,该患者在鼻塞、乏力和反复呕吐 9 天后出现唤醒水平下降(格拉斯哥昏迷量表 12)和心动过缓,考虑脑膜炎,转入本院接受更高级别的治疗。在医院外进行的脑脊液(CSF)检查结果显示,患者出现低甘油三酯血症、蛋白质升高、单核细胞增多,脑膜炎聚合酶链反应检测结果仅对 HHV-6 呈阳性。有造影剂和无造影剂的脑磁共振成像显示基底蝶窦为主的脑膜强化模式,以及中度脑室肿大,伴有脑室周围水肿,这与急性交流性脑积水有关。考虑到脑脊液检查、神经影像学检查和最近的墨西哥旅行史,中枢神经系统(CNS)结核(TB)是主要的怀疑病例,并针对这一推断诊断开始了抗菌治疗,培养数据在培养近 2 个月后才证明结核怀疑是正确的。最初认为没有必要进行抗病毒治疗,因为 HHV-6 被认为是偶发的,而不是导致免疫功能正常的宿主出现症状性脑膜炎的原因。对患者的脑积水进行了临时脑脊液转流治疗,随后进行了内镜下第三脑室造口术。尽管对脑积水进行了适当的处理,但临床症状的改善最终似乎与抗病毒治疗的启动有关:作者介绍了这一病例,并回顾了有关 HHV-6 相关中枢神经系统感染的文献,旨在让神经外科医生了解这种在临床上经常被低估的病原体。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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