Pitfalls associated with the diagnosis of herpes simplex encephalitis

ABSTRACTHerpes simplex encephalitis (HSE) still remains a serious illness with high morbidity and mortality. The characteristic presentation of HSE usually consists of fever, headache, and altered mental function. We present three patients with atypical features of HSE. First, a 48‑year‑old man with symptomatic posttraumatic epilepsy, who developed a gastrointestinal infection, seizures, and fever. After significant clinical improvement, the patient had fever again and developed a status epilepticus, which led to the diagnosis of HSE. Second, an 84‑year‑old woman with hyperactive delirium after levofloxacin intake. Cranial computed tomography (CCT) revealed hypodense temporal changes, prompting lumbar puncture and diagnosis of HSE. Third, a 51‑year‑old diabetic woman presented with fever and acute confusion. As CCT and cell count of cerebrospinal fluid (CSF) were normal, infection and hyperglycemia as initial diagnoses were postulated. Due to aphasic symptoms, the differential diagnosis of a stroke was taken into account. Thus a second lumbar puncture led to the correct diagnosis of HSE. These atypical presentations need a high grade of suspicion and a high willingness to reconsider the initial working diagnosis, in order to prevent a diagnostic delay.

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Remote cerebellar hemorrhage after lumbar puncture in herpes simplex encephalitis

Neurology and Clinical Neuroscience ◽

10.1111/ncn3.12018 ◽

2015 ◽

Vol 3 (6) ◽

pp. 229-231

Author(s):

Ruka Nakata ◽

Masakatsu Motomura ◽

Minoru Morikawa ◽

Toshiro Yoshimura ◽

Atsushi Kawakami

Keyword(s):

Herpes Simplex ◽

Lumbar Puncture ◽

Herpes Simplex Encephalitis ◽

Cerebellar Hemorrhage ◽

Remote Cerebellar Hemorrhage

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Focal Encephalitis With Enterovirus Infections

PEDIATRICS ◽

10.1542/peds.88.4.841 ◽

1991 ◽

Vol 88 (4) ◽

pp. 841-845

Author(s):

John F. Modlin ◽

Ron Dagan ◽

Linda E. Berlin ◽

David M. Virshup ◽

Robert H. Yolken ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Herpes Simplex ◽

Children And Adolescents ◽

Lumbar Puncture ◽

Pediatric Patients ◽

Herpes Simplex Encephalitis ◽

Focal Seizures ◽

Group A ◽

Focal Encephalitis ◽

Cerebrospinal Fluid Pleocytosis

We report on four pediatric patients with Enterovirus infections who were admitted to the hospital with signs or symptoms of acute, focal encephalitis. All four experienced focal seizures. Each had a cerebrospinal fluid pleocytosis at the initial lumbar puncture. In all four patients the diagnosis of herpes simplex encephalitis was entertained. Each child improved spontaneously within a few days of admission to the hospital, and only one had residual neurologic abnormalities at the time of discharge. A brief review of these cases, and three addditional cases from the literature, indicate that the enteroviruses, particularly the group A Coxsackieviruses, are rare causes of acute focal encephalitis in children and adolescents.

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Diagnostic delay in a case of herpes simplex encephalitis

BMJ Case Reports ◽

10.1136/bcr.12.2008.1350 ◽

2009 ◽

Vol 2009 (jun01 1) ◽

pp. bcr1220081350-bcr1220081350 ◽

Cited By ~ 3

Author(s):

Z. Shalchi ◽

A. Bennett ◽

D. Hargroves ◽

J. Nash

Keyword(s):

Herpes Simplex ◽

Herpes Simplex Encephalitis ◽

Diagnostic Delay

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Experience with Brain Biopsy for Suspected Herpes Encephalitis: A Review of Forty Consecutive Cases

Neurosurgery ◽

10.1227/00006123-198306000-00011 ◽

1983 ◽

Vol 12 (6) ◽

pp. 654-657 ◽

Cited By ~ 35

Author(s):

Richard B. Morawetz ◽

Richard J. Whitley ◽

Dennis M. Murphy

Keyword(s):

Herpes Simplex ◽

Ct Scan ◽

Bacterial Infections ◽

Herpes Simplex Encephalitis ◽

Medical Center ◽

Correct Diagnosis ◽

Brain Biopsy ◽

Herpes Encephalitis ◽

Related Complication ◽

Anterior Portion

Abstract From January 1973 through July 1981, 40 patients underwent brain biopsy for suspected herpes simplex encephalitis at the University of Alabama Medical Center. Biopsy was performed as a component of experimental antiviral studies to ensure correct diagnosis. A tentative diagnosis was made on clinical grounds, and the site of biopsy was chosen on the basis of localizing neurological signs, the electroencephalogram, and/or computed tomographic (CT) scan abnormalities. Patients ranged in age from 15 months to 73 years, with a median age of 19 years. Thirty patients were male, and 10 were female. Brain tissue from 17 of the 40 patients grew herpes simplex virus in tissue culture. There was one biopsy-related complication, a wound dehiscence requiring secondary closure. In no case was death attributable to the brain biopsy procedure. The outlook in patients with proven herpes encephalitis worsened directly with both an increasing interval between the onset of symptoms and the initiation of antiviral therapy and the age of the patient. The presence of a CT scan abnormality before the initiation of therapy was associated with a very poor prognosis. Three patients not included in this series were referred for brain biopsy to rule out herpes simplex encephalitis, but were found to have bacterial infections. Two had subdural empyemas and the third had a brain abscess with overlying subdural empyema. Current technique calls for biopsy of the anterior portion of the inferior temporal gyrus on the affected side.

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Outcomes with acyclovir treatment in herpes simplex encephalitis after surgery for solid CNS tumors: a case report and systematic review of the literature

Neuro-Oncology Practice ◽

10.1093/nop/npz007 ◽

2019 ◽

Vol 6 (4) ◽

pp. 259-263 ◽

Cited By ~ 1

Author(s):

Niloofar Yari ◽

Ethan Alexander Benardete ◽

Wencong Chen ◽

Solomon Neba Ambe ◽

Ekokobe Fonkem

Keyword(s):

Herpes Simplex ◽

Herpes Simplex Encephalitis ◽

Cns Tumors ◽

High Morbidity ◽

Delay In Diagnosis ◽

Patient Demographics ◽

Acyclovir Treatment ◽

Specific Outcome ◽

Delayed Recognition ◽

Tumor Types

Abstract Background Herpes simplex encephalitis (HSE) occurring within 30 days after neurosurgery for solid CNS tumors is underrecognized and underreported but remains important because of high morbidity and mortality. We present the case of a 41-year-old woman who had HSE after craniopharyngioma surgery, and delayed recognition and treatment led to a poor outcome. Subsequently, we review reported HSE cases after neurosurgery for solid CNS tumors and describe outcomes after treatment with and without acyclovir. Methods A literature search was performed for cases meeting the above criteria. Information was gathered regarding patient demographics, tumor types, symptoms, diagnostic workup, therapy, and outcomes. Results Eighteen cases were studied. Encephalopathy, fever, and seizures were the most common symptoms. A majority of patients (78%) received IV acyclovir, with a 79% survival rate with treatment. Mortality rate was 100% in untreated cases. The median time to starting acyclovir was 17 postoperative days (range, 8-53 days). Most patients received steroids, but its use was not associated with a specific outcome. Conclusions HSE may develop following neurosurgical resection, and the threshold for suspicion of this condition should be extremely low in a patient who shows compatible symptoms (encephalopathy, fever, or seizures) or does not recover as planned. Moreover, in case of suspicion of HSE, acyclovir should be promptly started until infection can be definitely ruled out. A delay in diagnosis of HSE and failure to treat may result in severe morbidity as well as mortality. This observation may warrant further study.

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An Alternative Elastase-mediated Degradation of Fibrinogen and Fibrin Observed in a Patient with Herpes Simplex Encephalitis and Pneumonia

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650550 ◽

1996 ◽

Vol 76 (02) ◽

pp. 184-186 ◽

Cited By ~ 2

Author(s):

Kenji lijima ◽

Fumiyo Murakami ◽

Yasushi Horie ◽

Katsumi Nakamura ◽

Shiro Ikawa ◽

...

Keyword(s):

Herpes Simplex ◽

Blood Cell ◽

White Blood Cell ◽

Herpes Simplex Encephalitis ◽

Pmn Elastase ◽

Cell Counts ◽

Blood Cell Counts ◽

Sds Page ◽

White Blood Cell Counts ◽

Pmn Élastase

SummaryA 74-year-old female developed pneumonia following herpes simplex encephalitis. Her white blood cell counts reached 28,400/μl, about 90% of which consisted of granulocytes. The polymorphonuclear (PMN) elastase/α1-arantitrypsin complex levels increased and reached the maximum of 5,019 ng/ml, indicating the release of a large amount of elastase derived from the granulocytes. The mechanism of PMN elastase release was most likely to be granulocyte destruction associated with phagocytosis. The cleavage of fibrinogen and fibrin by PMN elastase, independent of plasmin, was indicated by the presence of the fragments in immunoprecipitated plasma from the patient corresponding to elastase-induced FDP D and DD fragments and the absence of fragments corresponding to plasmin-induced FDP D and DD fragments on SDS-PAGE. These findings suggested that the large amount of PMN elastase released from the excessive numbers of granulocytes in this patient with herpes simplex encephalitis and pneumonia, induced the cleavage of fibrinogen and fibrin without the participation of plasmin.

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