Published online February 1, 2007
PEDIATRICS Vol. 119 No. 2 February 2007, pp. e399-e407 (doi:10.1542/peds.2006-1494)

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ARTICLE

A 12-Year Prospective Study of Childhood Herpes Simplex Encephalitis: Is There a Broader Spectrum of Disease?

Jorina M. Elbers, MD^a, Ari Bitnun, MD, MSc^b, Susan E. Richardson, MD^c, Elizabeth L. Ford-Jones, MD^b, Raymond Tellier, MD, MSc^c, Rachel M. Wald, MD^b, Martin Petric, PhD^c, Hanna Kolski, MD^a,d, Helen Heurter, BScN^b and Daune MacGregor, MD^a

^a Divisions of Neurology
^b Infectious Diseases, Department of Paediatrics
^c Department of Paediatric Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
^d Division of Neurology, Department of Paediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada

OBJECTIVE. The purpose of this study was to review the experience with herpes simplex encephalitis at the Hospital for Sick Children over the past 12 years.

METHODS. All patients who were admitted to our institution with acute encephalitis between January 1994 and December 2005 were enrolled prospectively in an encephalitis registry. Children from the registry with herpes simplex encephalitis were included in this study; we detailed the clinical presentations, laboratory findings, electroencephalographic findings, diagnostic imaging findings, treatments, and outcomes for all cases.

RESULTS. Of 322 cases of acute encephalitis, 5% were caused by herpes simplex virus. Initially negative herpes simplex virus cerebrospinal fluid polymerase chain reaction results were found in 2 cases (13%), but results became positive in repeat cerebrospinal fluid analyses. Classic clinical presentations were seen in 75% of cases, cerebrospinal fluid pleocytosis was found in 94%, elevated cerebrospinal fluid protein levels were found in 50%, electroencephalographic changes were observed in 94%, and diagnostic imaging abnormalities were noted in 88%. All patients were treated with intravenous acyclovir. Neurologic sequelae occurred in 63% of cases, including seizures in 44% and developmental delays in 25%. There were no deaths in this study group.

CONCLUSIONS. Herpes simplex encephalitis continues to be associated with poor long-term neurologic outcomes despite appropriate therapy. Cerebrospinal fluid polymerase chain reaction results may be negative early in the course of herpes simplex encephalitis; therefore, repeat cerebrospinal fluid analysis should be considered if herpes simplex encephalitis is suspected. Atypical forms of herpes simplex virus central nervous system disease may occur in children.

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Key Words: herpes simplex virus • encephalitis • children

Abbreviations: HSV—herpes simplex virus • HSE—herpes simplex encephalitis • CSF—cerebrospinal fluid • PCR—polymerase chain reaction • EEG—electroencephalographic • CT—computed tomography • CNS—central nervous system • RBC—red blood cell • PLEDS—periodic lateralizing epileptiform discharges • ADEM—acute demyelinating encephalomyelitis

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Accepted Aug 15, 2006.

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