Correspondence An Unusual Complication of Chemotherapy: Herpes Simplex Meningoencephalitis and Bilateral Acute Retinal Necrosis R. C. Nolan, , *, H. Van Gessel and M. Byrne* * Sir Charles Gairdner Hospital, Nedlands, Australia Royal Perth Hospital, Perth, Australia Sir – Caring for patients who become unwell while receiving chemotherapy can be challenging. The onset of a febrile illness during this time may be attributable to toxic effects of chemotherapy, opportunistic infections or the tumour itself. Accurate diagnosis and subsequent management may be crucial to long-term survival in people with curable disease. We report the unusual case of a man who developed meningoencephalitis and subsequent acute retinal necrosis due to herpes simplex virus type 2 (HSV2) while receiving chemotherapy for a pineal tumour. A retinal image taken during his illness has appeared elsewhere [1]. In this report, we highlight some of the difficulties encountered in diagnosis and management, and we make a case for maintaining prophylaxis against HSV during iatrogenic immune suppression in patients who have previously shown evidence of active infection. A 45-year-old man was diagnosed with a pineal parenchymal tumour of intermediate differentiation after biopsy of a bulky mass detected on magnetic resononance imaging. The treatment planned was three cycles of BEP chemotherapy (bleomycin, etoposide and cisplatin) followed by craniospinal irradiation given with curative intent. On day 9 of the first cycle of chemotherapy, the patient developed profound irritability, amnesia and altered personality. Lumbar puncture revealed monocytosis, raised protein and low glucose. He was given empirical treatment with intravenous ceftriaxone, amoxycillin, aciclovir and dexamethasone, as the broad differential diagnosis included a tumour lysis syndrome with cytokine release. HSV2 was detected using a multiplex nested polymerase chain reaction (PCR) targeting the HSV glycoprotein B gene on two separate cerebrospinal fluid samples. PCR for other viruses, including HSV1, VZV and enterovirus, was negative on both specimens. Subsequent serological testing demonstrated HSV2 IgG without IgM in cerebrospinal fluid and peripheral blood. He denied a history of previous genital ulceration. Treatment was continued with intravenous aciclovir (800 mg three times daily) for 3 weeks resulting in complete resolution of symptoms. The second cycle of chemotherapy was given without incident during this time. Development of acute retinal necrosis (ARN) affecting both eyes was preceded by 3 days of fever and personality change during the third cycle of chemotherapy, 17 days after cessation of aciclovir. Profound loss of vision occurred over a two hour period. HSV2 was detected in vitreous fluid by PCR. Treatment with methylprednisolone (1 g daily for 3 days) and intravenous aciclovir (800 mg three time daily for 4 weeks) improved ocular inflammation but not sight. The pineal tumour remains in stable partial remission after more than 20 months. Reactivation of latent HSV2 infection has been documented as a cause of recurrent aseptic meningitis (Mollaret's meningitis) [2], encephalitis [3]and ARN [4 and 5]. In our case, failure to continue antiviral treatment for the duration of systemic chemotherapy after proven HSV2 reactivation may have contributed to the ARN. In the setting of illness during chemotherapy, diagnostic efforts must focus on the identification of a possible infectious cause. HSV2 should be considered in all cases of meningoencephalitis, particularly in the setting of immunosuppression. Serious herpetic disease may not preclude intensive anti-tumour therapy, but consideration should be given to prophylaxis against recurrence for the duration of impaired immunity. Clinical Oncology Volume 16, Issue 1 , February 2004, Pages 81-82 Clin Onc, 2/04 J Clin Oncology, 3/04 Remember we are NOT Doctors and have NO medical training. This site is like an Encylopedia - there are many pages, many links on many topics. Support our work with any size DONATION - see left side of any page - for how to donate. You can help raise awareness of CAM.