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Letter
Mollaret-like Cells in Patients
with West Nile Virus Infection
Gary W. Procop,*
Belinda Yen-Lieberman,* Richard A. Prayson,* and Steve M. Gordon*
To the Editor: We have read with interest many of the articles
concerning West Nile virus (WNV) published in the July 2003 issue of Emerging
Infectious Diseases. Last summer Ohio was one of the leading states with
WNV infection in humans. Consequently, requests for tests for this pathogen
have increased. Unfortunately, the turnaround time for testing these specimens
may be delayed because of shipping difficulties, the limited number of
laboratories that can perform these assays, and an increase in requests
at testing facilities.
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Click to view
enlarged image
Figure. Three Mollaret-like cells are present
(center), with a neutrophil (upper left) and a lymphocyte (upper
right) in cerebrospinal fluid...
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Cytologic examination of cerebrospinal fluid (CSF) from patients with
WNV has not been studied. Although cytologic examination of CSF from patients
with encephalitis is likely nonspecific, it may provide supportive information
of the suspected disease process, and is useful for excluding other conditions,
such as neoplasia. Of the 22 patients that were hospitalized at our institution
last year with WNV meningoencephalitis, documented by serologic tests
and/or reverse transcription-polymerase chain reaction, CSF of 4 of these
patients was submitted for cytologic examination. Of these 4, 3 had a
sufficient number of cells in the CSF specimen (47, 213, and 495 cell/µL)
to afford cytologic examination, whereas one had a paucicellular CSF,
with only 2 white blood cells/µL. The cytologic features from the
3 patients with >10 cells/µL consistently demonstrated a mixture
of lymphocytes at various stages of activation and occasional large monocytic-like
cells with cerebriform nuclei reminiscent of the Mollaret cells described
in CSF of patients with recurrent meningitis (Figure)
(1).
Mollaret described cells with enlarged nuclei and cerebreform nuclear
contours in CSF of patients with recurrent, aseptic meningitis (1).
Although he believed these were of endothelial origin, immunohistochemical
studies have subsequently shown that they are monocytes (2).
This type of meningitis, now commonly known as Mollaret meningitis, has
been associated with herpes simplex virus encephalitis, but the definitive
cause of all cases remains unclear (3).
One of the patients infected with WNV meningoencephalitis who had Mollaret-like
cells in CSF died. Postmortem neuropathologic examination showed an extensive
perivascular lymphocytic infiltrate which contained mononuclear cells
consistent with the Mollaret-like cells in CSF. These mononuclear cells
were stained with an immunohistochemical stain directed against the CD68
antigen, which supports a monocytic origin (4). Further
studies are needed to delineate the consistency of Mollaret-like cells
in CSF of patients with WNV meningoencephalitis. Finding Mollaret-like
cells admixed with activated lymphocytes may be a useful, readily-available
test that provides supportive evidence of viral encephalitis in the appropriate
clinical setting, until more definitive tests are available.
References
- Mollaret MP. La meningite endothelio-leucotaire multirecurrent
benigne: Syndrome nouveau ou maladie nouvelle? Rev Neurol 1981;9:81–84.
- Stoppe G, Stark E, Patzold U. Mollaret’s
meningitis: CSF immunohistologic examinations. J Neurol 1987;234:103–6.
- Tedder DG, Ashley R, Tyler KL, Levin MJ. Herpes
simplex virus infection as a cause of benign recurrent lymphocytic meningitis.
Ann Intern Med 1994;121:334–8.
- Kelly TW, Prayson RA, Ruiz AI, Isada CM, Gordon SM. The
neuropathology of West Nile virus meningoencephalitis. A report of two
cases and review of the literature. Am J Clin Pathol 2003;119:749–53.
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