Indian J Sex Transm Dis Indian J Sex Transm Dis
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  Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 43  |  Issue : 1  |  Page : 72-74
 

Epstein-Barr virus infection presenting as encephalitis in HIV—Phenomenon not seen frequently


Department of Neurology, Dr. RML Hospital, New Delhi, India

Date of Submission04-Nov-2019
Date of Decision04-Feb-2021
Date of Acceptance28-Sep-2021
Date of Web Publication07-Jun-2022

Correspondence Address:
Dr. Abhishek Juneja
A-15, Old Quarters, Ramesh Nagar, New Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijstd.IJSTD_91_19

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   Abstract 


Epstein-Barr virus (EBV) infection can rarely present as encephalitis in HIV patients. We report a case of a 22-year-old female patient, diagnosed to have HIV infection 8 years back. She presented with headache and altered behavior for a week and focal fits for 2 days. Neurological examination was unremarkable. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with raised protein. EBV was detected in CSF using polymerase chain reaction test. Magnetic resonance imaging of the brain revealed T2/fluid-attenuated inversion recovery hyperintensities involving the left frontal cortex, left thalamus, and right medial temporal cortex. The patient was started on antiviral therapy considering the diagnosis of EBV encephalitis. The patient completely recovered over the next few weeks.


Keywords: Encephalitis, Epstein-Barr virus, HIV


How to cite this article:
Mahajan R, Anand KS, Juneja A, Garg J. Epstein-Barr virus infection presenting as encephalitis in HIV—Phenomenon not seen frequently. Indian J Sex Transm Dis 2022;43:72-4

How to cite this URL:
Mahajan R, Anand KS, Juneja A, Garg J. Epstein-Barr virus infection presenting as encephalitis in HIV—Phenomenon not seen frequently. Indian J Sex Transm Dis [serial online] 2022 [cited 2022 Nov 28];43:72-4. Available from: https://www.ijstd.org/text.asp?2022/43/1/72/346592





   Introduction Top


Patients with HIV infection are at higher risk of developing herpes central nervous system (CNS) infections. Among herpes viruses, cytomegalovirus, herpes simplex, and Epstein-Barr virus (EBV) are known to cause CNS infections in HIV-positive patients.[1] EBV is a B-lymphotropic virus that is associated with a variety of lymphoid malignancies in immunocompromised patients, including primary CNS and Burkitt's Lymphoma.[2] Rarely, it can also present as meningitis, encephalitis, transverse myelitis, and peripheral neuropathies.[3]


   Case Report Top


We report a case of a 22-year-old female patient, diagnosed to have HIV infection 8 years back. She was on antiretroviral therapy (ART) for the last 8 years. The patient had not been taking ART regularly for the last 2 years. Her CD4 count had gradually fallen to 238/mm3 from 520/mm3 over 2 years. She presented to us with complaints of headache and altered behavior for a week and focal fits for 2 days. She had holocranial, throbbing headache associated with episodes of vomiting. She was irritable and showed no interest in her surroundings. The mother found her muttering to herself for the last few days. She was scared and believed that someone wanted to kill her. Later, she had multiple fits in the form of right-sided facial twitching and clonic jerky movements of the right upper limb. There was no history of fever, neck pain, or loss of consciousness. Neurological examination was unremarkable. Her routine blood investigations were normal. CD4 count was 238/mm3. Cerebrospinal fluid (CSF) examination revealed total cell count of 30/mm3 with lymphocytic predominance. CSF protein was 68 mg/dl, while sugar was 72 mg/dl. On further testing, EBV was detected using polymerase chain reaction (PCR) test. While tuberculosis PCR, virology (including herpes simplex, varicella-zoster, cytomegalovirus, and JC virus), syphilis, toxoplasma serology, cryptococcal antigen, bacterial, and fungal cultures were negative in blood and CSF. The quantitative viral assay showed a high level of EBV in CSF (42,864 copies/ml). Magnetic resonance imaging of the brain revealed T2/fluid-attenuated inversion recovery hyperintensities involving the left frontal cortex left thalamus and right medial temporal cortex [Figure 1] and [Figure 2]. The patient was started on antiviral therapy with valganciclovir considering the diagnosis of EBV encephalitis. The patient completely recovered over the next few weeks. She was discharged on antiepileptic and ART.
Figure 1: T2 fluid-attenuated inversion recovery sequence of magnetic resonance imaging brain showing hyperintensity in the left frontal cortex

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Figure 2: T2 fluid-attenuated inversion recovery sequence of magnetic resonance imaging brain showing hyperintensity in the left thalamus

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   Discussion Top


Viral encephalitis in HIV-infected patients can be due to HIV per se and various other opportunistic pathogens. Cytomegalovirus and herpes simplex are the commonest viral infections of the CNS in HIV.[4] EBV infection can present as meningitis, encephalitis, and myelitis. These neurological complications usually occur after few weeks of the onset of acute infectious mononucleosis. EBV encephalitis has been reported in literature mainly in immunocompromised patients.[5] Rarely, neurological symptoms occur in the absence of systemic involvement as in our patient. Various hypotheses including infiltration of CD8 + T-cells into the neural tissue and deposition of antigen-antibody complexes in the endothelial tissue have been proposed.[6]

CSF PCR has been reported to be a useful quantitative test for diagnosing EBV-associated CNS disease.[7] It has a sensitivity of 80%.[7] Formal guidelines exist for the management of Herpes-simplex, cytomegalovirus, and Varicella-zoster-related encephalitis but not for EBV-associated encephalitis.[4] Ganciclovir and valganciclovir have been shown to reduce EBV viremia. There are reports of successful treatment of EBV-encephalitis with both these antiviral drugs.[8],[9] Our case highlights EBV as opportunistic infection in HIV-infected patients which may occur at relatively high CD4 counts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Martínez PA, Díaz R, González D, Oropesa L, González R, Pérez L, et al. The effect of highly active antiretroviral therapy on outcome of central nervous system herpesviruses infection in Cuban human immunodeficiency virus-infected individuals. J Neurovirol 2007;13:446-51.  Back to cited text no. 1
    
2.
Serraino D, Piselli P, Angeletti Cl, Scuderi M, Ippolito G, Capobianchi MR. Infection with Epstein-Barr virus and cancer: An epidemiological review. J Biol Regul Homeost Agents 2005;19:63-70.  Back to cited text no. 2
    
3.
Fujimoto H, Asaoka K, Imaizumi T, Ayabe M, Shoji H, Kaji M. Epstein-Barr virus infections of the central nervous system. Intern Med 2003;42:33-40.  Back to cited text no. 3
    
4.
Steiner I, Budka H, Chaudhuri A, Koskiniemi M, Sainio K, Salonen O, et al. Viral meningoencephalitis: A review of diagnostic methods and guidelines for management. Eur J Neurol 2010;17:999-e57.  Back to cited text no. 4
    
5.
Polilli E, Sozio F, Mazzotta E, Consorte A, Di Masi F, Agostinone A, et al. Rapidly progressive and fatal EBV-related encephalitis in a patient with advanced HIV-1 infection at presentation: A case report and review of the literature. New Microbiol 2010;33:275-80.  Back to cited text no. 5
    
6.
Connelly KP, DeWitt LD. Neurologic complications of infectious mononucleosis. Pediatr Neurol 1994;10:181-4.  Back to cited text no. 6
    
7.
Weinberg A, Li S, Palmer M, Tyler KL. Quantitative CSF PCR in Epstein-Barr virus infections of the central nervous system. Ann Neurol 2002;52:543-8.  Back to cited text no. 7
    
8.
Höcker B, Böhm S, Fickenscher H, Küsters U, Schnitzler P, Pohl M, et al. (Val-) Ganciclovir prophylaxis reduces Epstein-Barr virus primary infection in pediatric renal transplantation. Transpl Int 2012;25:723-31.  Back to cited text no. 8
    
9.
Cauldwell K, Williams R. Unusual presentation of Epstein-Barr virus hepatitis treated successfully with valganciclovir. J Med Virol 2014;86:484-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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