Skip to main content Accessibility help



  • Access
  • Cited by 1


      • Send article to Kindle

        To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Herpes simplex virus encephalitis in Peru: a multicentre prospective study
        Available formats

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Herpes simplex virus encephalitis in Peru: a multicentre prospective study
        Available formats

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Herpes simplex virus encephalitis in Peru: a multicentre prospective study
        Available formats
Export citation


Herpes simplex virus (HSV) is one of the most commonly identified infectious aetiologies of encephalitis in North America and Europe. The epidemiology of encephalitis beyond these regions, however, is poorly defined. During 2009–2012 we enrolled 313 patients in a multicentre prospective study of encephalitis in Peru, 45 (14·4%) of whom had confirmed HSV infection. Of 38 patients with known HSV type, 84% had HSV-1 and 16% had HSV-2. Patients with HSV infection were significantly more likely to present in the summer months (44·4% vs. 20·0%, P = 0·003) and have nausea (60·0% vs. 39·8%, P = 0·01) and rash (15·6% vs. 5·3%, P = 0·01) compared to patients without HSV infection. These findings highlight differences in the epidemiology and clinical presentation of HSV encephalitis outside of the Northern Hemisphere that warrant further investigation. Furthermore, there is an urgent need for improved HSV diagnostic capacity and availability of intravenous acyclovir in Peru.

Encephalitis is a potentially devastating condition in which the aetiology is often not identified [1, 2]. Studies of the aetiologies of encephalitis have been historically difficult because cases are sporadic and dispersed over large geographical areas, symptoms may be heterogenous, and diagnostic capacity in existing laboratories is often limited. The annual incidence of encephalitis in Western industrialized countries is about 5·2 cases/100 000 persons overall, or 2·2 cases/100 000 adults and 10·5–13·8 cases/100 000 children [3, 4]. In tropical settings, annual incidence in adults and children combined is an estimated 6·3 cases/100 000 [4]. Although several prospective studies of encephalitis have been conducted in developing countries [58], comprehensive information on the epidemiology and aetiologies of encephalitis outside of Western industrialized countries – and particularly in Latin America – is extremely limited.

Viral central nervous system (CNS) pathogens are most often identified using polymerase chain reaction (PCR) to detect viral RNA or DNA [9]. As PCR technology becomes more widely available, herpes simplex virus (HSV) is increasingly recognized as one of the most commonly identified aetiologies of encephalitis across the world [1013]. Two types of HSV affect humans: HSV-1 infection is acquired through oral transmission and is associated with cold sores, while HSV-2 infection is primarily acquired vertically or via sexual transmission. Both HSV-1 and HSV-2 encephalitis can occur during initial infection or as a result of reactivation, when a herpes virus that is dormant in ganglia of the nervous system reactivates to produce CNS infection [14]. Although CNS infection with HSV-2 after the neonatal period is uncommon, one study reported that 36% of women and 13% of men developed symptoms of meningitis during primary genital HSV-2 infection [15].

HSV encephalitis is a treatable form of encephalitis. Prior to the advent of intravenous acyclovir, mortality from HSV encephalitis was >70%; through treatment with intravenous acyclovir, mortality 18 months post-infection has declined to 28% [16]. Outcome is greatly improved when acyclovir is initiated within 2 days of symptom onset [14].

Current knowledge of aetiological agents of encephalitis in Latin America is primarily based on acute febrile illness surveillance [17] or small studies of limited geographical scope and duration [7, 18]. The objectives of this study were to determine the relative frequency of herpes as a cause of encephalitis in Peru and describe characteristics of patients with and without herpes encephalitis enrolled in a prospective study of CNS infections.

We conducted a prospective, multicentre, hospital-based study from 2009 to 2012 at 12 hospitals in five Peruvian cities: the capital city of Lima (seven hospitals), Iquitos in the Amazonian jungle (two hospitals), Trujillo in the coastal desert (one hospital), and Arequipa and Cusco in the Andes mountains (one hospital each) (Fig. 1).

Fig. 1. Map of the study area showing hospitals in five Peruvian cities.

A case was defined as any patient aged ⩾28 days with acute onset (<2 weeks) of neurological symptoms, such as change in level of consciousness, seizure, altered coordination, or dysphasia. In addition, one or more of the following signs or symptoms was required: fever (temperature ⩾38 °C), headache, cerebrospinal fluid (CSF) white blood cell count >5 leukocytes/ml, or neuroimaging or electroencephalography abnormalities suggestive of encephalitis. This case definition is similar to that proposed by the International Encephalitis Consortium but incorporates a slightly broader major criterion (neurological symptoms rather than mental status change) and requires one minor criteria rather than two [19]. Subjects were excluded if they weighed <4 kg or had clinical, CSF, or neuroimaging findings consistent with pathology other than encephalitis (e.g. stroke or bacterial meningitis). All patients with presumptive HSV encephalitis received empirical intravenous acyclovir, with treatment discontinued if HSV PCR testing was negative.

All patients were interviewed using a standardized questionnaire to collect information on demographics, medical history, and clinical symptoms. The study physician performed a complete physical and neurological examination. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were performed when a mass lesion or other pathology was suspected. Patients were asked to return for a convalescent blood draw and interview 14 days after initial presentation.

Serum and CSF samples were collected from patients at initial presentation. CSF glucose, protein, and cell count with differential were determined at local laboratories and aliquots were shipped to the U.S. Naval Medical Research Unit-6 in Lima for further testing. PCR assay for HSV-1/2 was performed on all acute CSF and serum samples and convalescent serum samples when available. Nucleic acid was extracted using the Qiagen QIAamp DNA Mini kit (Qiagen Sciences, USA) and PCR performed using specific primers KS30 and KS31 [20]. Positive results were confirmed by sequencing of the amplicon, which is specific to HSV-1/2, using the BigDye Terminator v. 3.1 Cycle Sequencing kit and 3100 Genetic Analyzer (Applied Biosystems, USA). Acute and convalescent serum samples were tested for HSV-1/2 IgM and IgG antibody using HerpeSelect ELISA test (Focus Diagnostics, USA).

We used a modified version of the case definition proposed by Granerod et al. to classify subjects with confirmed, probable or possible HSV encephalitis: confirmed if HSV was detected in CSF by PCR assay; probable if HSV IgG seroconversion was present; and possible if HSV was detected by PCR assay in serum on initial presentation or IgM serology was positive [21].

For univariate analyses, we included patients with confirmed, probable or possible HSV encephalitis. For the comparison of categorical variables among subjects, we used Pearson's χ 2 test for independence and Fisher's exact test. The Mann–Whitney U test was used for comparison of continuous variables when variables were not normally distributed. Statistical significance was defined as P ⩽0·05; all statistical tests were calculated two-sided. Data were analysed using Stata v. 12 (StataCorp., USA).

All study procedures were approved by study hospitals and by the Institutional Review Boards of the University of Washington and the U.S. Naval Medical Research Unit No. 6. Written consent was obtained from each subject or from a parent or legal guardian for subjects aged <18 years. Written assent was obtained from subjects aged 8–17 years.

Three hundred thirteen patients with encephalitis were enrolled in the study (Table 1). Most enrolled patients were from Lima (54·6%), followed by Trujillo (20·1%) and Iquitos (13·4%). The majority (62·3%) of patients were male; median age was 24·0 years (s.d. = 22·1, range 1 month-85 years). Subjects aged <20 years comprised 44·5% of the study population. The most common presenting symptoms and signs were: altered level of consciousness (96·1%), headache (80·9%) and fever (68·1%). The classic triad of fever, headache, and altered consciousness was present in 164 (52·4%) patients. Seizure was reported in 145 (46·3%) patients, cranial nerve deficit in 97 (30·1%), and hemiparesis in 69 (22·0%).

Table 1. Demographic and clinical characteristics of patients with and without HSV encephalitis in Peru, 2009–2012

CSF, Cerebrospinal fluid; IQR, interquartile range; PMNs, polymorphonucleocytes; RBC, red blood cell; WBC, white blood cell.

* There are two seasons in Peru – summer (December–March) and winter. In Lima and Trujillo the summer months are warmer than usual; in Iquitos, Arequipa, and Cusco the summer months are warmer and wetter than usual.

Results available for CSF findings: white cell count (n = 281), % lymphocytes (n = 236), % PMNs (n = 222), protein (n = 268), glucose (n = 254).

Non-parametric Wilcoxon rank-sum tests for continuous variables and Fisher's exact test for categorical variables.

Of the 313 patients with encephalitis, 45 (14·4%) had confirmed (n = 32), probable (n = 1), or possible (n = 12) HSV encephalitis. The highest proportion of patients with HSV infection were aged 30–39 years (26·2%), followed by patients aged 20–29 years (18·0%). Of these, 62·2% had fever and 50·0% had seizures on initial presentation. Thirty-two (71·1%) patients had HSV-1, six (13·3%) had HSV-2, and the remaining seven (15·6%) were inconclusive by HSV typing. HSV-2 encephalitis was detected only in patients aged <49 years.

Patients with (n = 45) and without (n = 268) HSV encephalitis were similar with respect to age, gender, and most presenting signs and symptoms. Compared to the 268 patients without HSV infection, those with HSV infection were significantly more likely to present in the summer months (44·4% vs. 20·0%, P = 0·003) and have nausea (60·0% vs. 39·8%, P = 0·01) and rash (15·6% vs. 5·3%, P = 0·01). In addition, patients with HSV encephalitis had significantly higher CSF white blood cell count (34 vs. 10 white blood cells/μl, P = 0·005) and percent lymphocytes (100% vs. 92%, P = 0·04). CSF protein and glucose levels, however, did not differ significantly between the groups.

Forty-four (14·1%) of the 313 enrolled patients returned for follow-up. Although information on patients' outcome was limited, we are not aware of any deaths of patients with HSV encephalitis; two patients with non-HSV encephalitis died.

This is the first report of community-acquired encephalitis from a prospective, multicentre study in Latin America. The proportion of subjects presenting with fever (68·1%) and seizure (46·3%) was similar to that reported by studies conducted in high-resource countries. However, a lower proportion presented with rash (6·7% compared to 11–13%) and a higher proportion with respiratory symptoms of rhinorrhoea, cough, or dyspnoea (48·9% compared to 20–33%) [1, 2].

The relative proportion of patients with encephalitis caused by HSV infection (14·4%) is higher than in some reports [1, 2] but consistent with others [11, 12, 22]. Of patients with HSV infection, the proportion with HSV-2 (13·3%) was similar to other reports [1, 14]. Similarly, the higher prevalence of HSV-2 in younger patients is consistent with our current understanding of disease [1, 16]. The seasonal predilection of HSV encephalitis found in this study was surprising but held true when the analysis was limited to patients with confirmed HSV encephalitis; this warrants further investigation since it has not been reported in other series [1, 22].

Our study had several limitations. First, Peru is very diverse in both its geography and populations, so subjects in our study may not be representative of the country as a whole. Furthermore, only patients who presented at hospitals were enrolled, so our sample was likely biased towards patients with more severe infections and access to transportation. Last, CT/MRI results were only rarely recorded and follow-up data was limited so we do not have complete information on patient imaging and outcomes.

Our findings highlight the importance of HSV infection as a commonly identified infectious cause of encephalitis in Peru. Diagnosis of HSV infection through PCR technology and treatment with intravenous acyclovir – the current standard of care – was not available in most Peruvian hospital prior to this study. Development of increased diagnostic capacity for detecting HSV and provision of intravenous acyclovir treatment required collaboration and support from regional and national hospitals and governments.

The high prevalence of HSV infection detected in patients across Peru emphasizes the need for expansion of HSV testing and increasing availability of intravenous acyclovir for treatment of HSV encephalitis in Peru and likely other countries. Furthermore, additional information about regional and seasonal differences in the aetiologies of encephalitis could guide physicians in clinical management and selection of empirical therapy in areas where access to diagnostic tools is limited.

APPENDIX. Meningoencephalitis Working Group

US Naval Medical Research Unit-6, Callao, Peru: A. Romero, N. Gadea; Dos de Mayo Hospital, Lima, Peru: J. Soria; Hospital Edgardo Rebagliati Martins, Lima, Peru: D. Huanca, A. Delgado; Hospital San Bartolome, Lima, Peru: M. Rivas, M. Stiglich; Hospital Felipe Santiago Arriola Iglesias, Loreto, Peru: G. Donayre, J. Celis; Hospital Daniel Alcides Carrion, Callao, Peru: R. Romero, N. Tam; Hospital Cayetano Heredia, Lima, Peru: M. Tipismana, I. Espinoza; Hospital Regional Cusco, Cusco, Peru: M. Rozas; Hospital Carlos Alberto Seguin, Arequipa, Peru: A. Peralta; Hospital Hipolito Unanue, Lima, Peru: E. Sanchez, L. Vasquez, P. Muñoz; Hospital Emergencias Pediatricas, Lima, Peru: G. Ramirez, I. Reyes.


The authors thank the study hospitals, Ministry of Health of Peru, and many collaborators for their dedicated involvement and support. Thanks are also due to Mallory Erickson for creating the map of study locations.

Funding for this study was provided by NIH Fogarty International Center grant RO1NS55627 to Joseph R. Zunt. This work was also supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental & Craniofacial Research, National Institute on Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases Health, and NIH Office of Women's Health and Research through the International Clinical Research Fellows Program at Vanderbilt University (R24 TW007988).

The opinions and assertions made by the authors do not reflect the official position or opinion of the government of the Republic of Peru, the Ministry of Health of Peru, or the U.S. Department of the Navy or Army.

Dr Montano and Dr Tilley are employees of the U.S. Government. This work was prepared as part of their official duties.




1. Glaser, CA, et al. Beyond viruses: clinical profiles and etiologies associated with encephalitis. Clinical Infectious Diseases 2006; 43: 15651577.
2. Granerod, J, et al. Causes of encephalitis and differences in their clinical presentations in England: a multicentre, population-based prospective study. Lancet Infectious Diseases 2010; 10: 835844.
3. Granerod, J, et al. New estimates of incidence of encephalitis in England. Emerging Infectious Diseases 2013; 19: 9.
4. Jmor, F, et al. The incidence of acute encephalitis syndrome in Western industrialised and tropical countries. Virology Journal 2008; 5: 134.
5. Ho Dang Trung, N, et al. Aetiologies of central nervous system infection in Viet Nam: a prospective provincial hospital-based descriptive surveillance study. PLoS One 2012; 7: e37825.
6. Giri, A, et al. Aetiologies of central nervous system infections in adults in Kathmandu, Nepal: a prospective hospital-based study. Scientific Reports 2013; 3: 2382.
7. Bastos, MS, et al. Detection of Herpesvirus, Enterovirus, and Arbovirus infection in patients with suspected central nervous system viral infection in the Western Brazilian Amazon. Journal of Medical Virology 2014; 86: 15221527.
8. Srey, VH, et al. Etiology of encephalitis syndrome among hospitalized children and adults in Takeo, Cambodia, 1999–2000. American Journal of Tropical Medicine and Hygiene 2002; 66: 200207.
9. Weber, T, et al. Clinical implications of nucleic acid amplification methods for the diagnosis of viral infections of the nervous system. Journal of Neurovirology 1996; 2: 175190.
10. Selim, HS, et al. Microbial study of meningitis and encephalitis cases. Journal of the Egyptian Public Health Association 2007; 82: 119.
11. Rathore, SK, et al. Viral aetiology and clinico-epidemiological features of acute encephalitis syndrome in eastern India. Epidemiology and Infection 2014; 142: 2514–2512.
12. Ghannad, MS, et al. Herpes simplex virus encephalitis in Hamadan, Iran. Iranian Journal of Microbiology 2013; 5: 272277.
13. Cinque, P, et al. The role of laboratory investigation in the diagnosis and management of patients with suspected herpes simplex encephalitis: a consensus report. The EU Concerted Action on Virus Meningitis and Encephalitis. Journal of Neurology, Neurosurgery and Psychiatry 1996; 61: 339345.
14. Kennedy, PG, Steiner, I. Recent issues in herpes simplex encephalitis. Journal of Neurovirology 2013; 19: 346350.
15. Corey, L, et al. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Annals of Internal Medicine 1983; 98: 958.
16. Whitley, RJ, Gnann, JW. Viral encephalitis: familiar infections and emerging pathogens. Lancet 2002; 359: 507513.
17. Forshey, BM, et al. Arboviral etiologies of acute febrile illnesses in Western South America, 2000–2007. PLoS Neglected Tropical Diseases 2010; 4: e787.
18. Espinoza, IO, et al. Enteroviral central nervous system infections in children treated at a hospital in Lima, Peru. Revista Peruana de Medicina Experimental y Salud Publica 2011; 28: 602609.
19. Venkatesan, A, et al. Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clinical Infectious Diseases 2013; 57: 11141128.
20. Aydemir, O, et al. The relationship of graft survival and herpes simplex virus latency in recipient corneal buttons. Clinical Ophthalmology 2007; 1: 127131.
21. Granerod, J, et al. Causality in acute encephalitis: defining aetiologies. Epidemiology and Infection 2010; 138: 783800.
22. George, BP, et al. Encephalitis hospitalization rates and inpatient mortality in the United States, 2000–2010. PLoS ONE 2014; 9: e104169.