Case Report Pathobiology Pathobiology 1996:64:59-63 Stealth Viral Encephalopathy: Report of a Fatal Case Complicated by Cerebral Vasculitis W. John Martin Key Words Abstract Encephalopathy Encephalitis Chronic fatigue Stealth Vasculitis A patient presenting with a severe subacute encephalopathy was shown to be infected with a stealth virus. Although the patient partially recovered, he remained lethargic with cognitive impairment and worsening headaches. Ten months after the onset of his illness, his clinical condition further deteriorated with seizures, coma and death. A brain biopsy revealed vacuolated degenerate neural cells consistent with a stealth viral encephalopathy. Focal perivascular lymphocytic inflammation was present within the leptomeninges and to a less­ er extent within the parenchyma of the brain. Vasculitis may occasionally con­ tribute to the complex symptomatology of stealth viral encephalopathy. Introduction Case Report KARGER E-Mail kargcr@kargcr.ch F ax + 41 61 306 12 34 http://www. karger.ch a 1996 S. Karger AG. Basel 10 15-2008/96/0642-0059$ 10.00/0 The 33-year-old Hispanic male was an outgoing, energetic indi­ vidual working as a laborer. He had no prior significant medical his­ tory. Over a 2-week period in July 1993. he lost his appetite, com­ plained of headaches and became depressed, irritable and reclusive. The day before hospital admission, he refused to eat. barely spoke and, what was said, was incoherent to his family. He became nonco­ operative and only reluctantly was persuaded to come to the emer­ gency room of the Los Angeles County Hospital. He was considered to have a psychiatric illness but was admitted, under restraints, to a medical ward to ‘rule out organic disease’. Although he was fully con­ scious when admitted, he became more somnolent over the next sev­ eral days and progressed into coma. There were no localizing neuro­ logical signs. The patient was treated empirically with amphotericin B. flucytosine and acyclovir. Initial and subsequent CSF examina­ tions were traumatic but indicative of a significant pleocytosis. The CSF white blood cell (WBC) counts per cubic millimeter were 128 on the day of admission, and 169, 60 and 17 on days 7, 12 and 19 post­ admission. Polymorphonuclear (PMN) cells were seen on the sam­ ples collected on the day of admission and at day 7. constituting 29 and 7%, respectively, of the total WBC. At the lime of admission, his Dr. W. John Martin Center for Complex Infectious Diseases 3328 Stevens Ave. Rosemead. CA 91770 (USA) Received: March II. 1996 Accepted: April 1 .1996 Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/16/2018 7:32:37 PM Specialized viral cultures and sensitive molecular probe-based assays have identified stealth viral infections in patients with a wide range of neuropsychiatric dysfunc­ tional brain disorders (information available at URL http://www.ccid.org). The spectrum of diseases seen in stealth viral-infected patients probably reflects the inten­ sity and predominant localization of infection occurring within the brain. It may also be affected by secondary autoimmune responses directed against neural antigens, and by indirect effects on blood supply resulting from involvement of the brain’s blood vessels. This paper describes the clinical and histological findings seen in a patient in whom a stealth viral infection was complicated by cerebral vasculitis. HSV CMV R e a g e n ts only P atie n t’s C S F Normal DNA Fig. 1. T2-\veighted MRI obtained dur­ ing the first hospital admission o f the pa­ tient. Multiple loci of abnormal high signal intensity can be seen within the basal gan­ glia. The Tl-weightcd MR1 was essentially normal. Positive DNA Fig. 2. The left-side panel shows the weak positive dot blot hybridization ob­ tained on the patient's CSF using CMV-reactive primers and probe in a low stringency PCR assay. The right side panel shows the negative result using HSV-reactivc primers. The positive controls were l : 100 dilutions of cultures infected with CMV and HSV, re­ spectively. Uninfected cells were used as a source of negative DNA. The HSV primers and low stringency PCR conditions are as described [4], peripheral blood WBC count was 11.900 with 77% PMN. The CSF protein level was 61 mg/dl on the day of admission (normal upper limit 50 mg/dl) and within normal limits at the other times of collec­ tion. His CSF IgG level was measured on the sample collected on day 19 postadmission and was slightly elevated (36 mg/dl). Moreover, electrophoresis showed weak but discernible oligoclonal banding [data not shown], CSF glucose levels were normal at each time point. He had an elevated erythrocyte sedimentation rate of 28 mm (nor­ mal upper limit 20 mm) and a 1:40 antinuclear antibody titer show­ ing a speckled pattern. The patient was HIV-negative. CSF cultures for fungal organisms, acid fast bacilli and conventional viruses gave negative results. Magnetic resonance imaging (MR1) was performed at 5 and at 19 days postadmission. Both studies showed multiple areas of abnormal high signal intensity within basal ganglia (fig. 1). These changes were seen in the T2-weightcd, but not in the T iweighted images. There was no meningeal enhancement. An EEG was interpreted as indicative of a mild encephalopathy consistent with a toxic, metabolic or infectious etiology. Specifically, it showed diffuse slow wave activity in the background plus intermittent poly­ morphic delta activity and occasional sharp waves over both tempo­ ral regions, mostly on the right side. Polymerase Chain Reaction Studies As shown in figure 2. a weak positive reaction was seen in a poly­ merase chain reaction (PCR) assay performed on the patient's CSF using a human cytomegalovirus (CMV) primer set and probe. The primers used were originally designed to amplify a region of the 60 » Pathobiology 1996:64:59—63 Fig. 3. CSF cytology showing a clump of cells with vacuolated cytoplasmic changes, x 400. CMV UL 83 gene (pp65 protein coding gene) between nucleotides 119.422 and 119.560 of the AD 169 strain of CMV [1], Under low stringency PCR conditions, these primers yield weak positive re­ sponses with other herpesviruses, including herpes simplex virus (HSV), human herpesvirus-6, varicella zoster virus and Epstein-Barr virus [2], The primers have been used to detect a subset of stealth viruses [2. 3. unpubl. data]. The CSF sample gave a negative result using PCR primers reactive with the immediate early (1-E) gene of CMV [1] and with a primer set reactive with HSV (fig. 2). Specialized blood cultures [4] were undertaken to test for the presence o f a stealth virus. A vacuolating syncytial cytopathic effect, typical of that induced with other stealth viral isolates [4], developed on MRC-5 human fibroblasts, rhesus monkey kidney cells and SP9 insect cells. The infected cells did not stain with antisera specific for human CMV 1-E antigen [4]. Anomalous PCR products were, how­ ever. generated from the infected cultures using the broadly reactive CMV primers in a low stringency PCR assay [data not shown], A CSF cytology sample, obtained on admission, was reexamined. Small clumps of atypical cells with foamy, vacuolated cytoplasmic changes were identified (fig. 3). The patient's mental and physical condition gradually improved over the 3 weeks he spent within the County Hospital. He was trans­ ferred to a convalescent hospital where he continued to slowly improve over a 10-week period. He was discharged to the care of his family and instructed to report for outpatient rehabilitation therapy. The rehabilitation service, however, considered that he was mentally too disabled to benefit from therapy and advised him to wait for a Martin Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/16/2018 7:32:37 PM # more complete recovery. There was little or no improvement over the ensuing months. The patient showed little interest in outside activities and complained of severe fatigue, nervousness, increasing headaches and more generalized aches and pains. He slept for several hours each day and his major activity was to watch television without much comprehension. His memory of the days’ events was impaired and he communicated poorly with his family. Ten months from the onset of his initial illness, his clinical condition acutely deteriorated. He no longer spoke to family members and one day became extreme­ ly listless and in apparent pain. The next morning he developed a generalized tonic-clonic seizure lasting 10 min which was controlled by Valium administered by paramedics. He was transported uncon­ scious to a community hospital. The patient was comatose with resid­ ual contractions involving both eyelids. His CSF contained 17 eryth­ rocytes, 21 WBC' (76% lymphocytes. 13% polymorphs and 11% monocytes), protein 68 mg/dl and glucose 61 mg/dl. Two subsequent CSF taps showed no abnormalities. An MRI examination was reported as normal while a second MRI showed minimal evidence of cerebral atrophy and unremarkable minor aberrations in periventric­ ular regions. No localizing signs were found on neurological examina­ tion. The patient awoke the next day but was aphasic and nonresponsive to attempted communications. His muscle tone was increased and although there was no voluntary movement, he would move in response to pain. His pupils responded sluggishly to light and his gag reflex was intact. Because o f the prior history of probable encephali­ tis. a right temporal lobe brain biopsy was performed. The patient never regained consciousness and died in asystole 2 weeks after admission. An autopsy was not performed. The brain biopsy showed a moderate, but patchy, perivascular lymphocytic inflammation affecting several of the blood vessels with­ in the leptomeninges (fig. 4). The vasculitis was nongranulomatous and not associated with fibrinoid degeneration or hemorrhage. A small number of the blood vessels within the brain were also infil­ trated with mononuclear cells (fig. 5). The larger blood vessels were generally only focallv affected with nearby blood vessels remaining uninvolved (fig. 6). There was essentially no inflammation extending from the focal vasculitis into the parenchyma of the brain. Many of Stealth Virus Vasculitis Fig. 5. Focal lymphocytic vasculitis involving a proportion of a cerebral blood vessel, x 400. A Fig. 6. Vascular inflammation affecting a cerebral blood vessel. An adjacent blood vessel remains relatively uninvolvcd in the inflammatory process, x 400. the neuronal cells showed evidence of a cytopathic effect with dis­ torted nuclei and fine vacuolating cytoplasmic changes (fig. 7, 8). Electron microscopy was not performed. Discussion Viruses which can induce vacuolated foamy cell changes in fibroblast and kidney cell cultures have been cultured front patients with a wide spectrum of neurologi­ cal and neuropsychiatric disorders [3-6], Support for an etiological role in these diseases has been provided by the Pathobiology 1996:64:59-63 61 Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/16/2018 7:32:37 PM Fig. 4. A region of localized perivascular lymphocytic inflamma­ tion present within the leptomeninges of the brain biopsy, x 100. Fig. 8. A cell showing vacuolated cytoplasmic changes and a dis­ torted degenerate nucleus seen within the brain biopsy. Nuclear changes are present in several additional cells seen in the section, x 400. demonstration of similar cellular changes in the brain of virus inoculated cats [7] and in the brains of severely ill, viral culture-positive patients [6], These in vivo changes occurred in the absence of the marked inflammatory changes that normally accompany herpesviral encephali­ tis. Indeed, the paucity of inflammation led to the sugges­ tion that the atypical viruses lacked the major immuno­ genic components required for effective T cell immunity. These viruses were provisionally termed ‘stealth' because of their apparent ability to avoid effective immunity in vivo, and because they were not being recognized using 62 Pathobiology 1996;64:59-63 Acknowledgements 1 wish to thank Dr. P. Colleti and Dr. S. Martin for the MRI and CSF cytology photographs. Martin Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/16/2018 7:32:37 PM Fig. 7. A normal blood vessel in the vicinity of a cell with a degen­ erate nucleus and finely vacuolated cytoplasm, x 400. conventional viral culture procedures. Molecular studies have shown that some of the stealth viruses are deriva­ tives of herpesviruses, most notably African green mon­ key CMV [8]. Sequencing studies have not been per­ formed on the virus isolated from the patient described in this paper. This patient is reported primarily because of the histo­ logic evidence of an appreciable vasculitis, especially affecting leptomeningeal blood vessels. This finding was in addition to the characteristic distorted nuclear and vacuolated cytoplasmic changes seen in many of the neu­ ral cells. The vasculitis was not suspected clinically nor indicated by the MRI examinations conducted during the final hospital admission [9]. Cerebral vasculitis can occur in association with many types of viral infection [10] and may be explained by sev­ eral mechanisms, including: (1) egress of cells from the vasculature into the tissues in response to immunogenic viral or modified self antigens expressed on viral-infected parenchymal cells; (2) response to antigen-antibody com­ plexes formed between circulating antibodies and the viral antigens diffusing from the infected tissues, and (3) direct viral infection of the blood vessel causing a dis­ ruption of the endothelial barrier function preventing lymphocyte adhesion and invasion. The patchy nature of the vasculitis and the involvement of varying-sized blood vessels tend to argue against major roles for the first two mechanisms. CMV has a propensity to infect blood ves­ sels [11] and certain stealth viruses might be expected to show the same potential. Cerebral vasculitis is commonly diagnosed, with or without angiographic confirmation, on the basis of recur­ rent seizure activity, headaches and transient neurological deficits [9], Clincially, it often responds to steroid and/or antimetabolite therapy such as cytoxan or methotrexate [12], Although a vasculitis is not a necessary component of stealth viral infection, it does help explain the seizure which led to the patient’s final hospitalization. Earlier vascular changes may also explain the rather striking bas­ al ganglia MRI findings seen on the initial hospitalization. The potential contribution of an accompanying vasculitis to severe stealth viral infections is currently being ad­ dressed in other patients. References Stealth Virus Vasculitis 4 Martin WJ. Zeng LC. Ahmed K. Roy M: Cyto­ megalovirus-related sequences in an atypical cytopathic virus repeatedly isolated from a pa­ tient with the chronic fatigue syndrome. Am J Pathol 1994:145:440-451. 5 Martin WJ: Stealth virus isolated from an au­ tistic child. J Autism Dev Disord 1995:25:223— 224. 6 Martin WJ: Severe stealth virus encephalopa­ thy following chronic fatigue syndrome-like ill­ ness: Clinical and histopathological features. Pathobiology 1996:64:1-8. 7 Martin WJ, Glass RT: Acute encephalopathy induced in cats with a stealth virus isolated from a patient with chronic fatigue syndrome. Pathobiology 1995;63:115-118. 8 Martin WJ. Ahmed KN. Zeng LC. Olsen JC. Seward JG, Seehrai JS: African green monkey origin of the atypical cytopathic ‘stealth virus' isolated from a patient with chronic fatigue syndrome. Clin Diagn Virol 1995:4:93-103. 9 Harris KG. Tran DD. Sickels WJ. Cornell SH. Yuh WTC: Diagnosing intracranial vasculitis. The roles of MR and angiography. Am J Neu­ roradiol 1994:15:317-330. 10 Jennctte JC, Falk RJ: Update on the pathobiologv of vasculitis. Monogr Pathol !995;37: 156-172. 11 Golden MP. Hammer SM. Wanke CA, Al­ brecht MA: Cytomegalovirus vasculitis. Case reports and review of the literature. Medicine 1994:73:246-255. 12 Calabrese LH, Duna GF: Evaluation and treat­ ment of central nervous system vasculitis. Curr Opin Rheumatol 1995:7:37-44. Pathobiology 1996:64:59-63 63 Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 9/16/2018 7:32:37 PM 1 Shibata D. Martin WJ. Appleman MD, el al: Detection of cytomegaloviral DNA in periph­ eral blood of patients infected with human immunodeficiency virus. J Infect Dis 1988; 158:1185-1 192. 2 Martin WJ: Detection of viral related se­ quences in CFS patients using the polymerase chain reaction: in Hyde B (ed): The Clinical and Scientific Basis of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Ottawa. Nightingale Res Found. 1992. pp 278-282. 3 Collard RP. Mavr A. Rice DA. Martin WJ: Herpesvirus-related sequences in salivary gland tumors. J Exp Clin Cancer Res 1996:15: 1-4.