Course Of Acyclovir Research Articles

Should a hospitalized child receive empiric treatment with acyclovir?

BackgroundHerpes simplex encephalitis is associated with substantial morbidity and mortality and may be related to timely diagnosis and treatment. While awaiting the results of testing, hospitalization and empiric treatment with acyclovir is recommended, though the direct and indirect costs associated with this management are substantial. We sought to examine children hospitalized for possible herpes simplex encephalitis, following clinical and laboratory assessment in the emergency department, and empiric treatment with acyclovir, in order to describe the proportion receiving a complete course of treatment; and to identify the clinical variables which are associated with receiving a complete course, as compared with an incomplete course of acyclovir.MethodsHospitalized children prescribed acyclovir were included in this case control study. Clinical, laboratory and diagnostic variables were abstracted for children prescribed a complete (≥ 14 days) or an incomplete course (<14 days) of acyclovir. Odds ratios and 95% confidence intervals were calculated.Results289 children met eligibility criteria, 30 (10%) received a complete course and 259 (90%) received an incomplete course. A history of mucocutaneous herpes simplex virus infection (p < 0.01), Glasgow Coma Scale ≤ 13 (p = 0.02), focal neurologic findings (p = 0.001) and elevated cerebrospinal fluid white blood cell count (p = 0.05) were associated with a complete course of acyclovir.ConclusionsMany children did not complete a full course of therapy. Unnecessary testing and treatment is burdensome to families and the health care system. Possible predictive variables include abnormal Glascow Coma Scale, focal neurologic findings and cerebrospinal fluid pleocytosis.

371 Rare Presentation of Acute Demyelinating Encephalomyelitis in A Child with Excessive Fatigue and Sleepiness

The encephalopathic child is a paediatric emergency and presents a considerable challenge.We present a 4 year old boy who was admitted with 3 week history of excessive fatigue and sleepiness,...

Changes in the Soluble Mucosal Immune Environment During Genital Herpes Outbreaks

Genital tract secretions provide variable inhibitory activity against herpes simplex virus (HSV) ex vivo. We hypothesize that the anti-HSV activity may prevent the spread of virus from the more commonly affected sites, such as the external genitalia, to the upper genital tract. The antimicrobial activity of cervicovaginal lavage (CVL) and concentrations of mucosal immune mediators were measured in 10 HIV-seronegative women with an active external herpetic lesion and compared with 10 HIV-seronegative women who were HSV-1 and HSV-2 seronegative. Samples were obtained at the time of a symptomatic external lesion (day 0), after 1 week of oral acyclovir (day 7), and 1 week after completing treatment (day 14). Controls were evaluated at parallel intervals. The anti-HSV activity was higher in CVL obtained from cases compared to controls at presentation (day 0) (54.3% vs. 28%), fell to similar levels on day 7, and then rebounded on day 14 (69% vs. 25%). The anti-HSV activity correlated positively and significantly with the concentrations of several inflammatory proteins; the concentrations of these proteins tended to be higher in cases compared with controls and followed a similar temporal pattern. Increases in inflammatory immune mediators and anti-HSV activity were detected in CVL at the time of clinical outbreaks and after completion of a short course of acyclovir. These mucosal responses may protect against HSV spread but could facilitate HIV infection and contribute to the clinical observation that, independent of clinical lesions, HSV-2 is a risk factor for HIV acquisition.

Clinical Reasoning: Encephalopathy in a 10-year-old boy

A 10-year-old, right-handed boy with a several-day history of fever and upper respiratory symptoms presented with acute onset headache, emesis, progressive mental status change, and right-sided focal seizures. Symptoms developed over approximately 3 hours. There was no history of recent toxic or medication exposures, travel, immunizations, sick contacts, insect bites, or animal exposures. The general review of systems was negative. ### Question for consideration: 1. What is your initial differential diagnosis based on this information? Initial differential diagnosis should include infection (encephalitis or meningitis), inflammation (connective tissue disease/autoimmune disease, primary or secondary vasculitis, antineuronal antibody mediated encephalopathy), demyelination (e.g., acute disseminated encephalomyelitis), a vascular event (ischemic or hemorrhage), and a malignancy such as a glioma or lymphoma. The patient was loaded with phenytoin and treated empirically with acyclovir and antibiotics while further history was obtained. He was the product of a normal pregnancy and term delivery. His developmental history was normal. Two years prior, he had a similar episode of fever and encephalopathy, which was associated with left-sided focal seizures and left hemiparesis. CT at that time demonstrated swelling of the right temporal lobe. He was presumptively diagnosed with herpes encephalitis, and received a full course of acyclovir. CSF herpes simplex virus (HSV) PCR was negative on 2 occasions. At his …

Encephalitis in the Pediatric Population

1. Stephen J. Falchek, MD* 1. *Division of Pediatric Neurology, Alfred I. duPont Hospital for Children/Thomas Jefferson University, Wilmington, DE, and Philadelphia, PA. * Abbreviations: ADEM: : acute disseminated encephalomyelitis CEP: : California Encephalitis Project CNS: : central nervous system CPP: : cerebral perfusion pressure CSF: : cerebrospinal fluid HSV: : herpes simplex virus IVIG: : intravenous immune globulin MS: : multiple sclerosis PCR: : polymerase chain reaction WNV: : West Nile virus Management of encephalitis, which can be fatal, requires understanding of a broad range of causative agents, pathophysiologic mechanisms, clinical syndromes, and outcomes. After completing this article, readers should be able to: 1. Know the many causes of encephalitis, including infectious, parainfectious, and noninfectious disorders. 2. Recognize the clinical features of encephalitis. 3. Be able to conduct a diagnostic investigation of a patient with encephalitis by using clinical and laboratory criteria. 4. Know the anticipated clinical course of different types of encephalitis. 5. Be familiar with the modalities used to treat encephalitis. 6. Understand the factors that influence the outcome in a patient who has encephalitis. The broad definition of the term “encephalitis,” that is, inflammation of the brain , necessitates acknowledgment of the enormous inclusivity of the topic. The most common interpretation of the term implies a direct invasion of the brain by an infectious pathogen, most commonly, viral, fungal, or parasitic. The topic also includes examples of meningitis mediated by bacteria or other agents, which can produce extrameningeal symptoms such as lethargy or seizures, in which case, the combined term “meningoencephalitis” is used. There are also many examples of encephalitis not due to direct central nervous system (CNS) infections. Inflammatory processes due to an acute or chronic illness can result in an acute immune-mediated encephalitis, such as acute disseminated encephalomyelitis (ADEM), lupus cerebritis, and paraneoplastic syndromes. Agents or conditions that produce slowly progressive CNS symptoms, such as tertiary syphilis or “slow viruses” (the prion protein encephalopathies), also are considered examples of encephalitis. Table 1 lists only a limited number of the many pathogens and pathologic conditions that can cause either acute or subacute encephalitis. In this discussion, …

Herpes Zoster Virus: An Unusual but Potentially Treatable Cause of Sciatica and Foot Drop

The herpes zoster virus is a rare but potential cause of acute motor weakness. This article describes 2 patients with drop foot secondary to an infection of varicella zoster who were incorrectly referred to an orthopedic clinic from their general practitioners. The first patient was a 74-year-old man who presented with weakness in the right foot and a vesicular rash. The pattern of disease supported the clinical diagnosis of shingles affecting the L5 motor and sensory division. No investigation was required, and the patient was treated with a foot drop splint. The second patient was a 71-year-old man who presented with right leg and foot weakness and a vesicular rash affecting his right buttock and posterior right thigh. Lumbar magnetic resonance excluded a stenotic lesion; electrophysiological studies supported the diagnosis of a lower motor neuron lesion. The patient was treated with a 1-week course of acyclovir and a foot drop splint. The correct diagnosis will aid in correct referral and will prompt management, which will potentially provide a faster and better outcome for the patient.

Population-Based Surveillance for Neonatal Herpes in New York City, April 2006–September 2010

Population-based data for neonatal herpes simplex virus (HSV) infection are needed to describe disease burden and to develop and evaluate prevention strategies. From April 2006 to September 2010, routine population-based surveillance was conducted using mandated provider and laboratory reports of neonatal HSV diagnoses and test results for New York City resident infants aged ≤60 days. Case investigations, including provider interviews and review of infant and maternal medical charts and vital records, were performed. Hospital discharge data were analyzed and compared with surveillance data findings. Between April 2006 and September 2010, New York City neonatal HSV surveillance detected 76 cases, for an average incidence of 13.3/100,000 (1/7519) live births. Median annual incidence of neonatal HSV estimated from administrative data for 1997 to 2008 was 11.8/100,000. Among surveillance cases, 90.8% (69/76) were laboratory confirmed. Among these, 40.6% (28/69) were HSV-1; 39.1% (27/69) were HSV-2; and 20.3% (14/69) were untyped. The overall case-fatality rate was 17.1% (13/76). Five cases were detected among infants aged >42 days. In all, 80% (20/25) of the case-infants delivered by cesarean section were known to have obstetric interventions that could have increased risk of neonatal HSV transmission to the infant before delivery. Over half (68%, or 52/76) of all cases lacked timely or ideal diagnostics or treatment. Administrative data may be an adequate and relatively inexpensive source for assessing neonatal HSV burden, although they lack the detail and timeliness of surveillance. Prevention strategies should address HSV-1. Incubation periods might be longer than expected for neonatal HSV. Cesarean delivery might not be protective if preceded by invasive procedures. Provider education is needed to raise awareness of neonatal HSV and to assure appropriate testing and treatment.

Acupuncture treatment of facial postherpetic itch

This report describes a case of moderate postherpetic dysaesthesia (specifically itch), partial success, and alteration in symptom behaviour from a treatment approach using acupuncture and briefly reviews plausible mechanisms behind the pathology and treatment effect.Case report: A 70-year-old woman developed facial dysaesthesia in January 2006, which rapidly spread over the left maxillary and ophthalmic distribution. She was diagnosed with postherpetic neuralgia and started on a course of acyclovir. Months after the initial attack of herpes zoster, a left sided dysaesthesia persisted and the patient underwent treatment with carbamazepine, which was poorly tolerated and discontinued. Acupuncture treatment commenced at 30 months post-onset, using a combination of Eastern and Western hypothetico-deductive reasoning and point selection. After 5 months of intermittent treatment, specifically 20 treatments, the outcome was a 50% decrease in symptom severity as self-reported by the patient using a numeric rating scale.Conclusions: Acupuncture has been shown in some studies, to alter some anatomical and physiological parameters of the hypothetical mechanisms of neuropathic itch. This case suggests that acupuncture treatment, years after the initiating event, in this case herpes zoster, can bring about clinically significant improvement with respect to perceived intensity and severity of neuropathic itch.

Legal Briefs

A 3,545-g, 35–3/7 weeks', large for gestational age (LGA) male is delivered to an insulin-dependent diabetic mother who became pregnant with the help of a fertility specialist. After conception, a general obstetrician managed her pregnancy. The antenatal course was uneventful except for a history of herpes simplex virus (HSV) infection. A cesarean section was planned at 38 weeks' gestation because of a relatively large fetus and a small pelvic outlet. The mother developed premature rupture of membranes (PROM) at 35 weeks' gestation, and 48 hours later, labor began. The obstetrician was out of town, and the mother was triaged to a midwife for the delivery. The mother's last HSV outbreak was 2 weeks before delivery, with lesions healing 4 days before delivery. The mother claimed in her deposition that she told the midwife about her history of herpes. The medical records from the fertility specialist and the obstetrician documented the history of HSV. The medical records reflecting the herpes were computerized and available to the midwife and the nurses who managed labor and delivery. The infant was delivered by a spontaneous vaginal vertex delivery. The Apgar scores were 8 at 1 minute and 9 at 5 minutes. The infant was asymptomatic and observed for 6 hours before rooming-in with his mother. Multiple bedside glucose evaluations were read as normal. A complete blood count (CBC) yielded unremarkable results. A blood culture was reported as negative on the final reading. Vital signs were stable. The infant was sleepy at the breast, but the mother fed him formula. The discharge examination was performed at 41 hours, and the only notable finding besides the LGA and late preterm gestation was that an ophthalmic examination could not be performed because the eyes were closed. The grandmother stated in her deposition that the baby's eyes were …

Herpes simplex ulcerative esophagitis in healthy children

Herpes simplex virus is a common cause of ulcerative esophagitis in the immunocompromised or debilitated host. Despite a high prevalence of primary and recurrent Herpes simplex virus infection in the general population, Herpes simplex virus esophagitis (HSVE) appears to be rare in the immunocompetent host. We report three cases of endoscopically-diagnosed HSVE in apparently immunocompetent children; the presentation was characterized by acute onset of fever, odynophagia, and dysphagia. In two cases, the diagnosis was confirmed histologically by identification of herpes viral inclusions and culture of the virus in the presence of inflammation. The third case was considered to have probable HSVE based on the presence of typical cold sore on his lip, typical endoscopic finding, histopathological evidence of inflammation in esophageal biopsies and positive serologic evidence of acute Herpes simplex virus infection. Two cases received an intravenous course of acyclovir and one had self-limited recovery. All three cases had normal immunological workup and excellent health on long-term follow-up.

An Unusual Etiology of Dysphagia in a Patient with Known Eosinophilic Esophagitis

Purpose: The natural history of eosinophilic esophagitis (EE) is poorly understood. Dysphagia, odynophagia, retrosternal chest pain, and episodes of food impaction are typical presenting signs and symptoms. Recurrence is common, even after initial response to inhaled corticosteroids and recurrent symptoms are often assumed to represent an exacerbation of EE. We discuss a patient with EE who presented with an unusual treatment-related complication, initially misdiagnosed as an exacerbation of EE. A 32-year-old woman with known eosinophilic esophagitis presented with severe odynophagia and dysphagia to liquids and solids of 2 days duration. Prior to the onset of symptoms, the EE was well controlled on fluticasone 220 mcg 1 puff twice daily. The pain was retrosternal and sharp in nature. She reported an episode of upper respiratory infection 1 week prior to admission. Esophagogastroduodenoscopy revealed severe esophagitis with linear white exudates in the mid to distal esophagus. Biopsies and brushings were performed. She was treated with fluconazole 100 mg daily for presumed fungal esophagitis and discharged the next day with mild to moderate improvement in symptoms. She returned to the hospital the next day with severe odynophagia and dysphagia. Although biopsies were still pending, no fungal elements were seen on the potassium hydroxide preparation. Worsening of her symptoms prompted the addition of intravenous solumedrol 125 mg daily for suspected severe EE. A hypoallergenic diet was also started. The following day the biopsies revealed extensive fibro purulent exudates, ulceration and histologic findings consistent with herpes esophagitis. Steroids were immediately stopped and she was placed on intravenous acyclovir 1 gram every 8 hours for 4 days. An HIV test was negative. She experience relief within 48 hours of antiviral therapy and was symptom free on discharge. She finished a 7-day course of acyclovir and has been symptom free in follow up. Herpes esophagitis is well described in immunocompromised and immunocompetent patients and presents with similar symptoms as EE. This case illustrates that herpes esophagitis is a potential complication of swallowed steroid treatment for EE and should be considered in the differential diagnosis of patients with known EE and recurrent symptoms.

Delayed Facial Palsy After the Anterior Petrosal Approach

In this case report, delayed facial palsy developed in a patient without any direct manipulation of the main part of the facial nerve during an anterior petrosal approach. We discuss putative etiologies and management techniques that may help avoid this problem. A 21-year-old woman underwent anterior petrosectomy for gross total resection of a low-grade chondrosarcoma. Six days later, the patient presented with left-sided facial weakness in the emergency department. Examination revealed evidence of House-Brackmann grade V/VI left-sided facial palsy, and repeat magnetic resonance imaging revealed diffuse enhancement of the contents of the internal auditory canal that was not present immediately after surgery. After a 10-day course of acyclovir and a tapering dose of methylprednisolone, the facial palsy slowly diminished and resolved 2 months after the onset. This unique development of delayed facial palsy after an isolated anterior petrosal approach is evidence that this complication should be considered when dissecting along the floor of the middle fossa. Exposure of the intracranial or intracanalicular segment of the facial nerve is not necessary for delayed facial palsy to develop. Proposed mechanisms (ie, viral reactivation, vasospasm, neural edema) of this condition remain unproven. Prognosis for recovery has been reported to be excellent, with or without treatment.

Coreoatetosis tras encefalitis herpética

After Herpes simplex encephalitis, 25% of cases may have a relapse, rarely as a choreoathetosic movement disorder. The anatomic basis for herpes simplex virus encephalitis-associated movement disorders remains poorly understood, but the hypothesis is that it may be due to a post-infectious immune-mediated process. We report an 8-month-old boy, with herpes simplex encephalitis type 1, who started with an extrapyramidal Syndrome, presenting with choreoathetosis and ballistic movements, three weeks after onset. These new symptoms were attributed to a post-infectious immune-mediated process. We treated our patient with corticosteroids at high dose and gamma-globulins, in addition to a new course of Acyclovir. Sedation was required to control the intense choreoathetosic movements. Tetrabenazine was also tried, unsuccessfully. We studied a mutation on the toll like receptors (TLR3), which has been related to susceptibility for the disease, which was negative.

Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi

To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.

Herpes Simplex Encephalitis in a Patient With Recurrent Pituitary Adenoma Receiving Radiation Therapy

A 61-year-old male initially presented with decreased libido and right visual field loss. Evaluation revealed an elevated prolactin level and a pituitary mass consistent with a secretory pituitary adenoma. His tumor progressed on cabergoline and he subsequently underwent transphenoidal tumor debulking. Four years later, his tumor recurred, and a second resection was performed. Postoperatively his dexamethasone was tapered from 16 to 4 mg/d and stereotactic radiation therapy (180 cGy per day to a planned dose of 5040 cGy) was initiated. Two weeks into his radiation, he suddenly began to speak incoherently and had a witnessed seizure with bowel and bladder incontinence while at home. He was evaluated in the hospital where he was found to be dyspneic and febrile to 38.7°C with fluent but nonsensical speech. His baseline bitemporal hemianopsia, right-sided ptosis, and facial droop with incomplete adduction of the right eye were stable. Admission studies revealed a white cell count of 7600/mL and a CD4 count of 104/mm3. Magnetic resonance imaging of the brain demonstrated an unchanged 2.0 × 2.2 × 2.5 cm pituitary mass (Fig. 1). Diffusion-weighted magnetic resonance imaging demonstrated a new area of restricted diffusion in the left mesial temporal lobe with corresponding hyperintensity on FLAIR (Fig. 2). The cerebrospinal fluid (CSF) contained 62 white cells/µL of which 95% were neutrophils, 53 RBC/µL, a protein of 45 mg/dL, and glucose of 81 mg/dL. Phenytoin was prescribed for his witnessed seizure, dexamethasone was increased for peritumoral edema, and given his fevers and CSF findings ceftriaxone, vancomycin and acyclovir were initiated. By day 3 of admission all bacterial and fungal cultures were negative, the CSF herpes simplex virus (HSV) polymerase chain reaction was positive, and other viral polymerase chain reactions were negative. The patient completed a 14-day course of acyclovir and returned to his baseline status, which was fully oriented, conversant, and able to care for himself. He had no further fevers or seizures and continued with the planned radiation therapy.

An unusual late complication of intracerebral haematoma in herpes encephalitis after successful acyclovir treatment

This is a case report of PCR proven herpes simplex (HSV-1) encephalitis in a 26 years old immunocompetent adult taking an unusual course of acute intracerebral haematoma after successful and complete recovery with acyclovir therapy. This transient late complication was associated with a negative repeat CSF PCR for HSV suggesting that the initial 14 days course of acyclovir was successful in the eradication of the herpes virus infection as recommended by the International Herpes Management Forum (IHMF). The location of the haematoma corresponded to the initial encephalitic area involving the medial temporal lobe structures. Despite this late neuroradiologic complication, after day 18 of symptom onset, the patient had a favourable neurological outcome. To the best of our knowledge, this is the second report of the unusual, rare, and late neuroimaging complication of acute intracerebral haematoma formation after complete recovery from treated HSVE with favourable clinical outcome. The literature is reviewed and plausible aetiology is discussed.

Herpes Simplex Virus Hepatitis Causing Acute Liver Dysfunction and Thrombocytopenia in Pregnancy

Herpes simplex virus (HSV) hepatitis in pregnant women is a rare condition. We report a case confirmed by liver biopsy and successfully treated with empiric intravenous acyclovir. A 25-year-old primigravida at 34 weeks of gestation presented with fever, thrombocytopenia, and markedly elevated liver enzymes. The patient was treated empirically and was delivered by cesarean. After delivery failed to correct her condition, a liver biopsy revealed HSV hepatitis. The fetus was unaffected and the patient recovered with an extended course of acyclovir. Pregnant women are susceptible to disseminated HSV causing hepatitis. A high index of suspicion is necessary to diagnose HSV hepatitis and begin appropriate treatment with acyclovir. Herpes simplex virus hepatitis should be included in the differential diagnosis for liver failure during pregnancy.

Herpes simplex virus type 1 and normal protein permeability in the lungs of critically ill patients: a case for low pathogenicity?

IntroductionThe pathogenicity of late respiratory infections with herpes simplex virus type 1 (HSV-1) in the critically ill is unclear.MethodsIn four critically ill patients with persistent pulmonary infiltrates of unknown origin and isolation of HSV-1 from tracheal aspirate or bronchoalveolar lavage fluid, at 7 (1–11) days after start of mechanical ventilatory support, a pulmonary leak index (PLI) for 67Gallium (67Ga)-transferrin (upper limit of normal 14.1 × 10-3/min) was measured.ResultsThe PLI ranged between 7.5 and 14.0 × 10-3/min in the study patients. Two patients received a course of acyclovir and all survived.ConclusionsThe normal capillary permeability observed in the lungs argues against pathogenicity of HSV-1 in the critically ill, and favors that isolation of the virus reflects reactivation in the course of serious illness and immunodepresssion, rather than primary or superimposed infection in the lungs.

A Randomised Placebo Controlled Trial of Suppressive Acyclovir in Late Pregnancy in Women with Recurrent Genital Herpes Infection

Objective To evaluate the efficacy and safety of a suppressive course of acyclovir in late pregnancy in women with recurrent genital herpes infection on the incidence of viral shedding, herpes lesion development and caesarean section for recurrent genital herpes. Design Double-blind, randomised placebo controlled clinical trial. Setting Adepartment of genitourinary medicine in Sheffield and an antenatal clinic in London. Population Pregnant women with recurrent genital herpes infection at < 36 weeks of gestation. Methods Participating women were given acyclovir 200 mg four times a day (or matching placebo) from 36 weeks of gestation until the time of delivery. Women were seen weekly and viral cultures were obtained from the cervix and vulva. Decisions regarding mode of delivery were left to the discretion of the attending obstetrician. Main outcome measures Delivery by caesarean section for recurrent genital herpes infection. Number of episodes of recurrent genital herpes infection and number of episodes of asymptomatic viral shedding during the treatment period. In addition blood was taken at two weekly intervals to determine acyclovir levels. Results The total number of women recruited was 63 (3 1 received acyclovir and 32 received placebo). The number of women undergoing delivery by caesarean section for recurrent herpes at the time of delivery was 12 (19%). The odds ratio for delivery by caesarean section in women taking acyclovir, compared with those talung placebo, was 0.44 (95% CI 0.09–1.59). The odds ratio for clinical recurrences during treatment was 0.10 (95% confidence interval 0.00–0.86) and the odds ratio for clinical recurrence or asymptomatic shedding during treatment was 0.32 (95% CI 0.05–1.56). Conclusion This trial was unable to demonstrate that acyclovir can significantly decrease the number of caesarean section deliveries; however, the number of clinical recurrences was significantly reduced. Two episodes of asymptomatic virus shedding both occurred in women taking acyclovir. At the present time there is little evidence to suggest that acyclovir should be used outside randomised controlled trials for the suppression of recurrent genital herpes infection during pregnancy.

ENCEPHALITIS IN A BOY FROM SOUTH CAROLINA

ENCEPHALITIS IN A BOY FROM SOUTH CAROLINA