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Table of Contents    
BRIEF REPORT
Year : 2019  |  Volume : 67  |  Issue : 5  |  Page : 1358-1359

An Investigation on the Coinfection of Measles and HSV-1 in Hospitalized Acute Encephalitis Syndrome Patients in Eastern India


1 Virology Division, ICMR-RMRC; Department of Biotechnology, School of Biotechnology, KIIT University, Bhubaneswar, Odisha, India
2 Virology Division, ICMR-RMRC; Department of Pediatrics, AIIMS, Bhubaneswar, Odisha, India
3 Virology Division, ICMR-RMRC, Bhubaneswar, Odisha, India
4 Department of Microbiology, Apollo Hospital, Bhubaneswar, Odisha, India
5 IMS and SUM Hospital, Director, Medical Research and Life Sciences, Bhubaneswar, Odisha, India

Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. B Dwibedi
Regional Medical Research Centre, Bhubaneswar - 751 023, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.271247

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 » Abstract 


Acute encephalitis syndrome (AES) is a clinical condition that occurs due to infectious and noninfectious agents- however, viruses are considered to be the dominant pathogen. agents- however, viruses are considered to be the dominant pathogen. In this study, suspected AES cases were enrolled and tested for viral etiology through serology and polymerase chain reaction (PCR)/reverse transcriptase PCR from August 2012–July 2013. During this period, 820 cases were investigated and 96 cases were diagnosed to have a viral etiology whereas 20 patients had IgM antibodies for measles in serum and HSV-1 DNA in cerebrospinal fluid. All 20 of the patients were children below 14 years of age. The median hospital stay was 15 days (IQR: 14.2-17 days) and median GCS score was 7(IQR: 6–8) and were significantly different with patients with co-infections when comapred with patients having HSV-1 infection only. It may be suspected that the measles infection may have a role in the pathogenesis and thus an impact on the prognosis of the AES when present with HSV-1.


Keywords: Acute encephalitis syndrome, dual infection, herpes simplex encephalitis, measles
Key Message: This investigation reported that measles infection may have some role in pathogenesis and prognosis of encephalitis when present along with HSV-1.


How to cite this article:
Rathore S K, Dwibedi B, Pati S S, Panda S, Panda M, Sabat J, Kar S K. An Investigation on the Coinfection of Measles and HSV-1 in Hospitalized Acute Encephalitis Syndrome Patients in Eastern India. Neurol India 2019;67:1358-9

How to cite this URL:
Rathore S K, Dwibedi B, Pati S S, Panda S, Panda M, Sabat J, Kar S K. An Investigation on the Coinfection of Measles and HSV-1 in Hospitalized Acute Encephalitis Syndrome Patients in Eastern India. Neurol India [serial online] 2019 [cited 2019 Dec 8];67:1358-9. Available from: http://www.neurologyindia.com/text.asp?2019/67/5/1358/271247




A cute encephalitis syndrome (AES) is a clinical condition associated with high morbidity and mortality. In India, most of the AES cases have been investigated during outbreak investigations where the focus is only on one virus. Even in hospital-based studies, cases of dual infection have either been under-reported or not been investigated properly.[1] In this investigation, we have tried to investigate the dual infection of measles and HSV-1 in AES patients in relation to their prognosis.


 » Materials and Methods Top


In this study, the definition of AES was adopted and cases were enrolled as per the guidelines of the National Vector Borne Diseases Control Program (NVBDCP)[2] during August 2012–July 2013 from seven hospitals in Cuttack and Bhubaneswar, within the state of Odisha. Demographic and clinical observations were recorded and samples [cerebrospinal fluid (CSF) and blood] were collected after obtaining consent from the guardian or accompanying person of the patients. Samples were subjected to serology or polymerase chain reaction (PCR)/reverse transcriptase PCR (RT-PCR) depending upon the date of the sample collection after onset of the illness. Early phase samples (within five days of illness) were subjected to PCR/RT PCR and antigen detection by ELISA, whereas IgM antibodies were tested in late phase samples (more than five days of illness). The laboratory investigation of IgM ELISA and PCR/RT PCR have previously been described.[3]

Descriptive statistics like frequency, proportion, median, and interquartile range were determined for each variable. Qualitative and quantitative data were compared between AES patients having dual infection and AES patients having only HSV-1infection by applying the proportion test and the Mann–Whitney U test, respectively. All the analysis was performed in the SPSS version 17.0. The study was conducted as a part of the ICMR virology grade-I laboratory activity under approval of the Human Ethical committee of the institution following the guidelines of the Indian Council of Medical Research (ICMR), New Delhi.


 » Results Top


Eight hundred and twenty AES cases were investigated and a viral etiology could be attributed to 96 (12.1%) cases; HSV-1 (46/820, 5.6%), HSV-2 (3/820, 0.36%), measles (36/820, 4.4%), JEV (5/820 0.6%), dengue (2/820, 0.24%), and enteroviruses (4/820, 0.48%). Of the 96 cases diagnosed for viral etiology, 20 AES cases were positive for both HSV-1DNA and measles IgM antibodies. All the subjects were children below 14 years of age (median age 5 years, IQR: 3.92–6.37) and had a history of measles infection prior to the hospitalization for AES. The male to female ratio was 1.8. The age of male children was 5 years (IQR: 4.15–5.85) whereas that the female median age was 6 years (IQR: 3.2–8). These patients were from 10 coastal districts of Odisha. Eighty-five percent of the patients were from rural areas and the majority of the patients had a low socioeconomic status. Of 20 cases, 15 parents (75%) could recall or show an card. Through this method, it was verified that 6/20 (30%) cases had received the measles vaccine. A comparison between AES patients with dual infection and AES patients with only HSV-1 infection has been shown in [Table 1]. Of note, it shows that the median age of the former group was significantly lower than later group (P = 0.0005). Likewise the median GCS score (median = 7; IQR: 6–8; P = 0.0015) and hospital stay (median = 15 days, IQR: 14.25–17.00; P = 0.0469) were significantly different in patients with dual infection from patients with HSV-1 infection. Rash was the only clinical symptom which was significantly higher in AES patients with dual infection (P = 0.001).
Table 1: Comparisonof factors between monoinfection of HSV-1 and dual infection

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 » Discussion Top


In this study, a viral etiology could be found in 12.1% of cases and rest remained undiagnosed. This may be due to autoimmune encephalitis, leptospirosis, toxoplasmosis or scrub typhus infection, etc. In addition, a delay in hospitalization as well as sample collection and unsuitable sampling might have been the factors for missing viral markers. HSV is an uncommon cause for viral encephalitis but it is the major pathogen in case of sporadic cases whereas the measles is a self-limiting disease and pose no threat until secondary complication ensues. It is known that measles results in the dysregulation of cell-mediated immunity that is used by the host to combat the herpes infection.[4],[5] In this situation, the longer hospital stay was due to low GCS scores, which could resulted from the above-mentioned dysregulation of cell-mediated immunity. This is a very preliminary observation, but it has clinical importance for patient management.

Financial support and sponsorship

The authors extend their sincere thanks to Indian Council of Medical Research, New Delhi for financial support towards fellowship of the PhD scholar and establishment of ICMR virology grade-I laboratory.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Joshi R, Kalantri SP, Reingold A, Colford JM. Changing landscape of acute encephalitis syndrome in India: A systematic review. Nat Med J India 2012;5:212-20.  Back to cited text no. 1
    
2.
Government of India. Available from: http://www.nvbdcp.gov.in/je-action-taken.html. [Last accessed on 2017 May 30].  Back to cited text no. 2
    
3.
Rathore SK, Dwibedi B, Kar SK, Dixit S, Sabat J, Panda M. Viral aetiology and clinico-epidemiological features of acute encephalitis syndrome in eastern India. Epidemiol Infect 2014;142:2514-21.  Back to cited text no. 3
    
4.
Atabani SF, Byrnes AA, Jaye A, Kidd IM, Magnusen AF, Whittle H, et al. Natural measles causes prolonged suppression of interleukin-12 production. J Infect Dis 2001;184:1-9.  Back to cited text no. 4
    
5.
Douglas RG, Couch RB. A prospective study of chronic herpes simplex virus infections and recurrent herpes labialis in humans. J Immunol 1970;104:289-95.  Back to cited text no. 5
    



 
 
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