We conducted a retrospective audit of the outcomes of patients 15 years of age and older from the greater Auckland region who had a diagnosis of encephalitis over a five-year period. Patients were identified via a database search of all patients who had a cerebrospinal fluid (CSF) viral polymerase chain reaction (PCR) panel requested between 2005 and 2009. All CSF viral PCR were performed at one laboratory. This test was used as a default marker for patients who may have had encephalitis. There were 37 patients who met our definition of encephalitis during the study. Their ages ranged from 15 to 88 years (median 51 years), and 59% were female. There was an admission rate of 7.4 admissions per year or an annual incidence of approximately 0.5 cases per 100,000. An infective cause was found in 10 patients (27%): varicella zoster in five patients (14%), herpes simplex in four (11%) and enterovirus in one patient (3%). An autoimmune paraneoplastic encephalitis was felt most likely in three patients (8%); a paraneoplastic antibody screen was performed in two of these three but was negative in both. The cause of encephalitis was not identified in the other 24 patients (65%). There were five deaths (in-hospital mortality rate 14%). Encephalitis is an uncommon but important disease, because of the significant mortality. The cause of encephalitis remained undetermined in two-thirds of patients.

Subacute sclerosing panencephalitis (SSPE) and subacute measles encephalitis (SME) are both rare complications of measles virus infection. SSPE typically affects immunocompetent children, has an insidious onset and follows a steadily progressive course. SME mainly occurs in immunosuppressed children and has a rapidly progressive course. We describe a 43 year old immunocompetent man who presented with a rapidly progressive fatal encephalopathy. Histological examination of the brain showed a meningoencephalitis with inclusion bodies. Complement fixing antibody to measles virus was present in his serum and CSF. Measles virus RNA was found in the brain, spinal cord and eye, but not in the CSF. Analysis of the nucleoprotein gene isolated from this patient did not show similarity to SSPE strains of the measles virus. This patient demonstrates that subacute encephalitis secondary to measles virus infection can develop in an immunocompetent adult host.

A 53-year-old man developed progressive sensory disturbance and weakness in the legs, sphincter disturbance, back pain, systemic symptoms, and pancytopenia. Electrophysiological tests indicated a widespread lumbosacral polyradiculopathy. Spinal magnetic resonance imaging and routine cerebrospinal fluid analysis showed minor nonspecific abnormalities. Bone marrow and liver biopsies showed hemophagocytosis; and polymerase chain reaction of cerebrospinal fluid, bone marrow, and serum suggested active infection with human herpesvirus-6. Autopsy revealed that his neurological symptoms resulted from intravascular lymphomatosis (angiotropic large cell lymphoma), a rare variant of lymphoma with predilection for the nervous system.

Erythema infectiosum, or fifth disease, has long been recognized as a common communicable disease of childhood. Since the identification of human parvovirus B19 (B19) in 1975, there has been increasing recognition of the spectrum of disease that can result from infection. Disease caused by B19 can vary depending on host factors. Infection in a normal host can be asymptomatic, manifest by a characteristic rash, or present with arthropathy. Primary infection during pregnancy can result in hydrops fetalis caused by fetal anemia. In an immunocompromised host infection may be prolonged and can present as chronic anemia without other features. Patients with sickle cell disease or other disorders of red blood cells may develop aplastic crisis during B19 infection. With the development of PCR for the detection of B19, the role of B19 in central nervous system infection is increasingly recognized. Case report. A 21/2-year-old girl presented in May, 1993, with pancytopenia and was diagnosed with acute lymphoblastic leukemia (low risk). Chemotherapy was given using the Australia and New Zealand Children's Cancer Study Group Study VI protocol. Treatment included vincristine, daunorubicin, L-asparaginase, prednisolone, cyclophosphamide, cytosine arabinoside, intrathecal methotrexate, mercaptopurine and oral methotrexate. Twenty months after diagnosis while receiving interval chemotherapy the child was admitted to hospital with a 2-week history of intermittent spiking fever and headache. She had been assessed by her general practitioner and treated with oral amoxicillin-clavulanic acid for a cough. Admission examination revealed a fever of 39°C with no apparent focus. A full blood count showed hemoglobin of 100 g/l, platelets of 92 × 109/l and a white blood cell count of 1.6 × 109/l (neutrophils 55% and lymphocytes 41%). Urinalysis and biochemistry were normal. Ceftazidime was given intravenously. After admission fevers persisted to 39.5°C, as did the headache. The child had two brief seizures associated with high fever; there was no past or family history of febrile seizures. There was progressive decline of the hemoglobin, platelets and white blood cell count. Examination remained normal with no meningism or neurologic abnormality. Results of a lumbar puncture on Hospital Day 3 are shown in Table 1. Cerebrospinal fluid (CSF) was cultured for bacteria and viruses, and antibiotic therapy was changed to intravenous cefotaxime. A computerized tomography head scan was normal.TABLE 1: CSF and PCR results Numerous investigations were negative, including CSF for Cryptococcus antigen and for Mycobacterium tuberculosis by culture and PCR. Studies for Toxoplasma (serology and PCR) were negative, as was cytomegalovirus PCR. Serology for Epstein-Barr virus was consistent with previous infection. Chest and sinus radiograms were normal. On Hospital Day 8 amphotericin B was commenced; cefotaxime was continued. Over Hospital Days 12 to 14 the headache and fever resolved. Amphotericin B and cefotaxime were stopped, and the child was discharged home on Day 16 with a diagnosis of a viral illness with meningitis. During the following week there was ongoing bone marrow suppression requiring interruption of oral chemotherapy. A bone marrow aspirate on Day 26 of the illness showed no evidence of leukemic relapse. A CSF obtained at the same time showed persistent abnormality. One month after hospitalization for this illness parvovirus B19 serology was positive for IgM and negative for IgG, and serum was strongly positive for B19 by PCR on the first round. Ten weeks later B19 IgM was still positive, B19 IgG was present and serum was positive for B19 by PCR, but only on the second round. Parvovirus B19 was detected in cerebrospinal fluid obtained during initial hospital admission and subsequently from repeat CSF 3 months later; CSF was negative for B19 by PCR 5 months after initial hospitalization. Six weeks after hospitalization there was spontaneous increase in hemoglobin, platelet count and white blood cell count. At no time was a rash present. The child is currently in remission, 3 years after the end of treatment. Laboratory methods.PCR. The nested PCR method was developed at the Auckland Public Hospital Virology Department. B19 recombinant plasmid DNA and positive control serum were obtained from B. Cohen (Virus Reference Laboratory, Central Public Health Laboratories, London, UK). Assay sensitivity was estimated to be ∼10 to 100 B19 genomes in a background of 1 μg of human DNA with the use of quantitated plasmid DNA. DNA was extracted from 200 μl of serum or CSF by standard methods using a sodium dodecyl sulfate lysis buffer plus proteinase K digestion, followed by phenol/chloroform extraction and ethanol precipitation. The DNA was resuspended in 50 μl of double distilled water. In the first round PCR 10 μl of DNA were used, followed by nested PCR with 2 μl of the first round product. Primer sequences were specific for the NS1 gene,1 first round amplification yielding a 446-base pair (bp) product and nested amplification yielding 235-bp internal product. PCR products were analyzed by 2% agarose gel electrophoresis followed by ethidium bromide fluorescence using UV light transillumination. Product identity was inferred from the electrophoretic comigration with amplified positive control product and the high level of specificity conferred by a nested PCR. Precautions taken to avoid false positive PCR results included separate laboratory rooms dedicated to specimen DNA preparation, PCR reagent/reaction preparation and PCR product amplification and detection. Blank control extractions accompanied all specimen DNA extractions. Further, no-DNA reactions were included in each PCR run to control for reagent contamination. Serology. Anti-B19 IgM and IgG antibodies were detected by enzyme-linked immunosorbent assay with kits obtained from MRL Diagnostics, Cypress, CA. B19 IgG reacts with B19 VP1 antigen bound to microwells. Subsequent detection was via a peroxidase-conjugated anti-human IgG antibody. IgM was similarly detected via a peroxidase-conjugated anti-human IgM (μ-chain-specific) antibody after first precipitating interfering IgG antibody. Discussion. This case clearly illustrates the atypical manifestations of B19 in an immunocompromised host, including chronic central nervous system (CNS) infection. The common signs of B19 infection in a normal host are primarily a result of the humoral immune response. A higher index of suspicion for this infection is needed in an immunocompromised host. Children undergoing chemotherapy who develop B19 infection can have a protracted period of bone marrow suppression.2-7 Intravenous gamma-globulin (IVIG) has been associated with clearance of viremia and resolution of bone marrow suppression.3 IVIG has also been used to treat B19 infection in primary immunodeficiency8, 9 and in patients with human immunodeficiency virus infection.4 Possible CNS infection in children with a clinical diagnosis of erythema infectiosum has been documented for some time.10, 11 With new techniques it has been possible to demonstrate B19 IgG and IgM12 and viral DNA by PCR13-16 in CSF. The cases of CNS infection reported to date have been in nonimmunocompromised children or adults, with associated features of bone marrow suppression and rash (Table 2).TABLE 2: Summary of reported cases of human parvovirus B19 CNS infection To our knowledge this is the first reported case of persistent CNS B19 infection. Given the lack of CSF contamination with blood, the CSF pleocytosis and the elevation in CSF protein, we believe this case represents true infection rather than falsely positive results. With the potential for treating B19 infection with IVIG infusion this case also illustrates the importance of considering B19 as a pathogen, especially in patients in whom one can predict that usual clinical features will not be present. Jan P. Sinclair, F.R.A.C.P. Margaret C. Croxson, F.R.C.P.A. Stephen M, Thomas. B.Sc. Lochie R. Teague, F.R.A.C.P., F.R.C.P.A. David C. Mauger, F.R.A.C.P. Starship Children's Hospital (JS, LT, DM) Virology Department; Auckland Public Hospital (KC, ST) Auckland, New Zealand

This report describes the containment of a potential enterovirus epidemic in a neonatal intensive care unit. A case of neonatal enterovirus meningitis and myocarditis was identified. Polymerase chain reaction (PCR) was used to assist in appropriate cohorting of contacts. One further infant became cross-infected with Coxsackie B4. Serum PCR was accurate in detecting the infection in the early stages in this asymptomatic neonate. Neonatal enterovirus infection is relatively rare but has the potential to cause outbreaks in neonatal wards. PCR can be used to diagnose and monitor for cross infection.

BACKGROUND:Although some studies have reported the presence of Mycobacterium tuberculosis (MTb) DNA in tissues affected by sarcoidosis, the data are conflicting. The aim of this study was to collect prospectively tissue from patients with sarcoidosis in whom tuberculosis had been excluded, and to use polymerase chain reaction (PCR) to search for DNA sequences specific for MTb.METHODS:Fresh tissue samples (node or lung biopsy) taken from 23 patients with newly diagnosed sarcoidosis, 10 with other respiratory disease, and four patients with culture positive tuberculosis were analysed using PCR to amplify a 123 bp fragment of IS6110, the insertion element present in MTb, and nested PCR to further amplify an 85 bp sequence within the 123 bp product. DNA was also extracted from formalin fixed tissue from eight additional patients with sarcoidosis.RESULTS:MTb DNA was not detected in any of the tissue samples from patients with sarcoidosis or other respiratory disease but was found in all four patients with tuberculosis.CONCLUSIONS:This study has shown the absence of MTb DNA in lymph node and lung biopsy samples from patients with sarcoidosis. MTb is therefore unlikely to be a factor in the pathogenesis of this disease.

We describe a 46-year-old man in whom retinitis was diagnosed as his initial HIV and AIDS defining illness, A diagnosis of CMV infection was made based on the clinical appearance of the fundus and confirmed by DNA polymerase chain reaction (PCR) on his vitreous biopsy, His CD4+ T lymphocyte count at the time was 580 x 10(6)/l (16%) with a CD4:CD8 ration of 0.28. He had a splenectomy following trauma more than 20 years earlier. He responded very well to intravenous and oral ganciclovir and remains recurrence-free almost 2 years later.This case and others highlight two issues: (i) CMV retinitis in HIV positive patients is not confined to those with very low CD4+ T lymphocyte counts; (ii) previous splenectomy may have an impact on CD4+ cell numbers and function.

Bilateral frontal and parietal opercular lesions cause a syndrome characterized by paralysis of the masticatory, facial, pharyngeal, and tongue muscles (the anterior opercular syndrome). The anterior opercular syndrome can occur in patients with herpes simplex encephalitis (HSE), but in most of these patients the diagnosis of HSE was not confirmed. We describe the anterior opercular syndrome in four patients with HSE. In two of these patients, the anterior opercular syndrome dominated the clinical picture, but in the other two patients it was overshadowed by other manifestations of HSE. The diagnosis of HSE was confirmed by detection of herpes simplex virus (HSV) DNA in the CSF (two patients), culture of the HSV from a brain biopsy (one patient), and elevated HSV antibody titers in the CSF (one patient). Our patients made a partial recovery. Acute onset of weakness of masticatory, facial, pharyngeal, and glossal muscles, accompanied by fever, headache, and partial motor seizures of the face should suggest HSE.

OBJECTIVES The frequency and characteristics of the long term sequelae of herpes simplex encephalitis were assessed after treatment with acyclovir. METHODS Patients were included if they were treated with acyclovir and the diagnosis of herpes simplex encephalitis was confirmed by culture of herpes simplex virus (HSV) from the brain, an increase in the CSF HSV antibody titre, or detection of HSV deoxyribonucleic acid in the CSF. Each patient’s medical records were reviewed and surviving patients were interviewed and examined. RESULTS A diagnosis of herpes simplex encephalitis was confirmed in 42 patients. Five patients (12%) died in the first month. Three patients (7%) had severe neurological sequelae and died after a longer interval. All but one of the 34 surviving patients had neurological symptoms, an abnormal neurological examination, or both. Twenty patients (48%) performed everyday activities as well as before herpes simplex encephalitis; nine patients (21%) were living independently, but were functioning at a lower level than before the illness; and five patients (12%) had a severe neurological deficit. Twenty nine of the 34 survivors were assessed six months to 11 years after herpes simplex encephalitis. The most common long term symptoms were memory impairment (69%), personality and behavioural abnormalities (45%), and epilepsy (24%). Short term memory impairment (70%), anosmia (65%), and dysphasia (41%) were the most common signs. CONCLUSIONS Although acyclovir has reduced the mortality of herpes simplex encephalitis, 30% of this group of patients either died or had a severe neurological deficit. The other 70% of the patients regained independence in activities of daily living, but most of these people had persistent neurological symptoms, signs, or both.

AIMS:To investigate the aetiology of recurrent lymphocytic meningitis in two patients with a past history of recurrent genital herpes simplex infection.METHODS:Cerebrospinal fluid (CSF) obtained from two patients during an acute recurrent episode of lymphocytic meningitis was analysed by polymerase chain reaction for the presence of herpes simplex DNA.RESULTS:In both patients, the acute CSF was positive for herpes simplex type 2 DNA. A second CSF obtained 2 weeks later from one patient was negative for HSV DNA:CONCLUSIONS:Herpes simplex type 2 may be an important cause of recurrent lymphocytic meningitis. Available evidence suggests that viral DNA is cleared from the CSF between episodes and supports active viral replication as the pathological mechanism. The recurrences of meningitis need not coincide with clinical recurrences of genital herpes.

Aims. To determine the human immunodeficiency virus (HIV) types infecting a West African immigrant to New Zealand. To develop an HIV type 2 specific polymerase chain reaction (PCR).Methods. The HIV antibody status of the patient was determined using both HIV-1 and dual HIV-1 and 2 enzyme immuno assays (EIA). Western blot with HIV-2 and HIV-1 and 2 strips was used as a confirmatory assay. DNA from white blood cells was extracted and HIV proviral DNA amplified using either primers specific to the HIV-2 gag region (VB305 and VB312) or to HIV-1 gag (SK38/39) and env (SK68/69) regions. Amplified products were electrophoretically resolved, southern blotted and probed with specific oligonucleotide probes.Results. The patient serum was strongly reactive for HIV antibodies by EIA and showed multiple reactivity when tested by western blot against both HIV-1 and HIV-2 proteins. DNA was only amplified with primers specific to HIV-2 and the 298 bp product hybridized with an HIV-2 specific probe. No HIV-1 DNA was amplified from the patient.Conclusion. This individual is infected with HIV-2 and has most likely developed antibodies that cross-react with HIV-1. We believe this is the first report of an HIV-2 infected individual in New Zealand.

Australian and New Zealand Journal of MedicineVolume 23, Issue 2 p. 216-217 Hypoplastic crisis with persistent arthralgia and prolonged parvovirus B19 viraemia detected by polymerase chain reaction M. G. CATTON, M. G. CATTON Registrar, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this authorS. M. THOMAS, S. M. THOMAS Scientific Officer, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this authorH. A. BLACKLOCK, H. A. BLACKLOCK Consultant Haematologist, Department of Haematology, Middlemore Hospital, Auckland, New Zealand.Search for more papers by this authorM. C. CROXSON, M. C. CROXSON Virologist in Charge, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this author M. G. CATTON, M. G. CATTON Registrar, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this authorS. M. THOMAS, S. M. THOMAS Scientific Officer, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this authorH. A. BLACKLOCK, H. A. BLACKLOCK Consultant Haematologist, Department of Haematology, Middlemore Hospital, Auckland, New Zealand.Search for more papers by this authorM. C. CROXSON, M. C. CROXSON Virologist in Charge, Department of Virology and Immunology, Auckland Public Hospital, Auckland, New Zealand.Search for more papers by this author First published: April 1993 https://doi.org/10.1111/j.1445-5994.1993.tb01820.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume23, Issue2April 1993Pages 216-217 RelatedInformation

A polymerase chain reaction (PCR) was used to detect herpes simplex virus (HSV) deoxyribonucleic acid (DNA) in CSF of 109 patients with possible herpes simplex encephalitis. HSV DNA was found in 20/109 patients. In 14 of these patients the diagnosis was confirmed by a rise in CSF antibodies, isolation of HSV from the brain, or both. In 3 patients CSF antibodies did not rise and 3 patients did not have a follow up lumbar puncture or a brain biopsy. In 19/20 patients HSV DNA was present in the first CSF specimen. The virus was identified as HSV I in 15 patients and HSV II in 4; the virus was not typed in the other patient. A possible diagnosis of herpes simplex encephalitis was not confirmed in the 89 PCR-negative patients. HSV DNA was present in CSF of 3 patients who had meningitis with herpetic genital infections but it was not found in 24 patients with other neurological diseases. The results suggest that the detection of HSV DNA in CSF using a PCR assay will be an accurate method of early diagnosis of herpes simplex encephalitis.

A presumptive clinical diagnosis of cytomegalovirus (CMV) retinitis was made in two patients presenting with atypical ophthalmologic findings. The diagnosis was confirmed by finding specific CMV DNA sequences in sampled vitreous fluid using a polymerase chain reaction (PCR) based assay. Neither of these patients yielded CMV on culture or PCR of peripheral blood leucocytes, nor was CMV present in tears or urine of either patient. Serum antibody titres were stable and did not help in establishing the diagnosis. This report suggests that CMV retinitis can occur in the absence of disseminated CMV disease.

This study investigates the use of polymerase chain reaction (PCR) in comparison with viral culture and serology for monitoring of cytomegalovirus (CMV) infection in 21 consecutive renal allograft recipients treated with a quadruple immunosuppression protocol. In addition, an attempt is made to explore the significance of quantitation of CMV signals obtained from peripheral blood leucocytes. CMV infection developed in 16 patients with seven of these patients having organ involvement. All of these 16 patients had a fourfold rise in antibody titres as well as positive identification of CMV DNA in peripheral blood leucocytes by PCR. Blood viral cultures were negative in two of these patients. All five patients who remained PCR negative also remained culture negative with no antibody change. PCR detected CMV infection on average 15 days and 20 days earlier than viral culture and serology respectively. All except one of the patients with CMV organ involvement had an initial peak of CMV DNA followed by prolonged carriage of detectable CMV. The majority of patients with fever only or asymptomatic CMV infection had a transient peak of CMV DNA. A high incidence of CMV disease with organ involvement occurred in seronegative recipients of kidneys from seropositive donors (3/5) and in seropositive recipients of kidneys from seronegative donors (3/7). OKT3 was associated with a higher incidence of CMV organ involvement compared to Antilymphocytic globulin (3/5 v 4/16) but there was a higher incidence of CMV mismatched patients in the OKT3 treated group.(ABSTRACT TRUNCATED AT 250 WORDS)

A 73-year-old man presented with acute hepatitis, judged to be a reactivation of hepatitis B virus infection. His serum samples during a follow-up time of 16 months showed an unusual pattern of serological markers. He was consistently HBeAg positive, HBsAg fluctuated just under the cut-off value and he had a low level of circulating anti-HBs. By electron microscopy numerous aggregates of surface antigen particles, but not complete virions were seen. He was HBV DNA positive by hybridization. The complete precore and core genes and a region of the surface gene were amplified from his serum by PCR. These findings emphasize the need for expanded serological testing in some patients with acute clinical hepatitis.

The value of a brain biopsy in diagnosis and management of suspected herpes simplex encephalitis was studied in 29 patients (16 prospectively and 13 retrospectively). The biopsy showed herpes simplex encephalitis in eight, culture-negative encephalitis in 14, and was normal in three patients. It provided an alternative diagnosis in four patients, for two of whom curative treatment was available. The biopsy was complicated by a fatal intracranial haemorrhage in one patient. The low yield of alternative diagnoses suggests that a brain biopsy is not justified in the routine investigation of focal encephalitis.

The HIV-1 infection status of two HIV-1 antibody positive infants born to HIV-1 infected mothers was determined using the polymerase chain reaction. HIV-1 genomic sequences were not detected in the white blood cells of either infant suggesting that they were not infected. HIV-1 genomic sequences were detected in the white blood cells of the mothers of both infants and in cells from the one surviving father. These results confirm the value of the PCR detection method for assessing the HIV-1 infection status of infants born to HIV-1 antibody positive mothers.