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Divyashree K, Singh H, Suri V, Bhalla A. Empirical intravenous aciclovir therapy in a suspected case of acute encephalitis. Trop Doct 2023; 53:321-324. [PMID: 36694451 DOI: 10.1177/00494755231152654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Herpes simplex encephalitis is the most common cause of sporadic viral encephalitis worldwide but presents as a diagnostic challenge at many settings due to its non-specific symptoms, which can be easily mistaken for systemic infection or metabolic encephalopathy. It has diverse range of presentations from fever, altered sensorium, nausea, vomiting, meningismus to seizures, neurological deficits and coma in advanced stages. It is associated with significant morbidity and mortality if treatment is delayed or inadequate. We here discuss a case of Herpes simplex virus (HSV) encephalitis which rapidly progressed to result in irreversible neurological insult due to delayed diagnosis and treatment.
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Affiliation(s)
- Krishna Divyashree
- Department of Internal Medicine, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harpreet Singh
- Department of Internal Medicine, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, 29751Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Zeng WG, Liao WM, Hu J, Chen SF, Wang Z. Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome mimicking herpes simplex encephalitis: A case report. Radiol Case Rep 2022; 17:2428-2431. [PMID: 35601382 PMCID: PMC9118100 DOI: 10.1016/j.radcr.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022] Open
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome presents with the features of herpes simplex encephalitis (HSE), which is rare and has been described in only a few case reports. Our case describes a 17-year-old female with no significant previous medical history presenting with an acute onset of fever, headache, and epilepsy, similar to HSE. Computed tomography of the brain showed bilateral basal ganglia calcification. Magnetic resonance imaging demonstrated gyriform restricted diffusion with T2-weighted images prolongation. Further investigation showed elevated blood lactate concentration at rest. Hence, MELAS was suspected and the diagnosis was confirmed by the presence of a nucleotide 3243 A→G mutation in the mitochondrial DNA. The clinical presentation and imaging studies of MELAS are variable and may mimic those of HSE. Infection may have also precipitated MELAS manifestation in this patient. Laboratory features, such as elevated lactate, basal ganglia calcification, and gyriform restricted diffusion may be helpful in identifying patients with MELAS.
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Key Words
- ADC, apparent diffusion coefficient
- Basal ganglia calcification
- CJD, Creutzfeldt-Jakob disease
- CSF, cerebrospinal fluid
- CT, computed tomography
- Case report
- CoQ10, coenzyme 10
- DNA, deoxyribonucleic acid
- DWI, diffusion weighted imaging
- FLAIR, fluid attenuated inversion recovery
- HS-CRP, high-sensitivity C-reactive protein
- HSE, herpes simplex encephalitis
- Herpes simplex encephalitis
- MELAS
- MELAS, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes
- MRA, magnetic resonance angiography
- MRI, magnetic resonance imaging
- NGS, next-generation sequencing
- NMDA, N-methyl-D-aspartate
- Next-generation sequencing
- PCR, polymerase chain reaction
- T1WI, T1-weighted image
- T2WI, T2-weighted image
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Affiliation(s)
- Wen-Gao Zeng
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Wan-Min Liao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Su-Fen Chen
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
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Abstract
Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.
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Abstract
PURPOSE OF REVIEW The goal of this review is to provide an update on current thinking regarding herpes simplex encephalitis (HSE), emphasizing new information about pathogenesis, diagnosis, and immune responses. Specific questions to be addressed are the following: (1) Is there a genetic predisposition to HSE? (2) What clinical approaches have the greatest impact on improving the long-term outcomes in patients with HSE? And (3) are there immune-mediated mechanisms that may account for relapsing HSE? RECENT FINDINGS Toll-like receptor 3 (TLR 3) plays an important role in innate immune responses, including generation of interferons. Multiple single-gene errors in TLR 3 interferon pathways have recently been described in children that result in increased susceptibility to HSE. Conversely, studies in both animal models and humans indicate that both cytolytic viral replication and immune-mediated responses (including cytotoxic T lymphocytes and immune mechanisms mediated by TLR 2) contribute to the pathology of HSV, suggesting possible new therapeutic approaches. In terms of treatment, data clearly indicate that a longer duration between onset of symptoms and initiation of effective antiviral therapy correlates directly with less favorable clinical outcome. Recurrent or relapsing HSE may occasionally occur, but recent observations indicate that many instances of "relapsing HSE", especially in children, are more often anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis triggered by the antecedent HSV infection. Innate immune responses are critical for defense against HSV; genetic defects in this system may predispose patients to HSE. During acute HSE, exuberant immune responses may contribute to the CNS pathology, suggesting that selective immunosuppressive therapy, coupled with potent antiviral drugs, may eventually play a role in the therapeutic management of HSV. While overall clinical outcomes of HSE remain suboptimal, the initiation of high-dose acyclovir therapy as early as possible in the course of the illness provides the best chance for a patient to survive with minimal neurologic damage. Distinguishing relapsing HSE from autoimmune anti-NMDAR antibody encephalitis is critically important because therapeutic approaches will be very different.
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Affiliation(s)
- John W Gnann
- Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Avenue, MSC 752, Charleston, SC, 29425, USA.
| | - Richard J Whitley
- University of Alabama at Birmingham, 303 CHB, 1600 7th Ave. S, Birmingham, AL, 35233-1711, USA
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Sonis J, Borczuk P, Ptak T, Miller ES. Seizure and Fever. J Emerg Med 2016; 50:773-7. [PMID: 26899515 DOI: 10.1016/j.jemermed.2016.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/21/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Jonathan Sonis
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pierre Borczuk
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Ptak
- Department of Radiology, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Cunha BA, Talmasov D, Connolly JJ. Herpes Simplex Virus (HSV-1) Encephalitis Mimicking Glioblastoma: Case Report and Review of the Literature. J Clin Med 2014; 3:1392-401. [PMID: 26237609 DOI: 10.3390/jcm3041392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/13/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022] Open
Abstract
Glioblastoma multiforme (GBM) often presents as a brain mass with encephalitis. In a patient with GBM, subsequent presentation with new onset encephalitis may be due to another GBM or Herpes simplex virus 1 (HSV-1) encephalitis. We present a case of HSV-1 encephalitis mimicking GBM in a patient with previous GBM.
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Affiliation(s)
- Tracey A Cho
- Department of Neurology, Harvard Medical School and Neuro-ID Program, Massachusetts General Hospital, Boston, MA, USA
| | - Robert R Mckendall
- Departments of Neurology and Microbiology & Immunology, University of Texas Medical Branch, Galveston, TX, USA.
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Abstract
Herpes 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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Affiliation(s)
- Ivana Vachalová
- Department of Neurology, Municipal Hospital Landshut, Germany
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Mesker A, Bon G, de Gans J, de Kruijk J. Case report: a pregnant woman with herpes simplex encephalitis successfully treated with dexamethasone. Eur J Obstet Gynecol Reprod Biol 2011; 154:231-2. [DOI: 10.1016/j.ejogrb.2010.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 09/09/2010] [Accepted: 10/13/2010] [Indexed: 11/20/2022]
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Fernandes AF, Lange MC, Novak FT, Zavala JA, Zamproni LN, Germiniani FM, Piovesan EJ, Teive HA. Extra-temporal involvement in herpes simplex encephalitis. J Clin Neurosci 2010; 17:1221-3. [PMID: 20541415 DOI: 10.1016/j.jocn.2010.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 01/13/2010] [Accepted: 02/07/2010] [Indexed: 10/19/2022]
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Alim KS, Alim SK. Herpes simplex encephalitis: A recent case. Pharmacotherapy 2010; 64:306-7. [DOI: 10.1016/j.biopha.2009.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 10/07/2009] [Indexed: 10/20/2022]
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Anand S, Crusio R, Tarkovsky R, Chapnick E. Acute Intracranial Hematoma in Herpes Simplex Encephalitis. Infectious Diseases in Clinical Practice 2010; 18:67-70. [DOI: 10.1097/ipc.0b013e3181aba442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Herpes simplex encephalitis (HSE) is the most frequent cause of sporadic fatal encephalitis in the Western world. Definitive diagnosis by viral PCR of cerebrospinal fluid (CSF) and treatment with aciclovir have improved the prognosis significantly. Nevertheless, the condition is rare and presents with non-specific symptoms that can easily be mistaken for systemic infection or non-infective encephalopathy. We report a case of HSE which was not recognised by four separate doctors, leading to substantial delay in diagnosis and treatment. Our patient presented with fever, headaches, altered behaviour and generalised bradykinesia. This was initially diagnosed as otitis interna (labyrinthitis) and, subsequently, an ischaemic stroke. There was a delay of 10 days in the initiation of aciclovir from symptom onset. MRI and CSF PCR confirmed herpes simplex virus type-1 (HSV-1) infection. The patient improved on aciclovir, but is disabled with word-finding difficulties and cognitive slowing.
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Affiliation(s)
- Zaid Shalchi
- William Harvey Hospital, Kennington Road, Willesborough, Ashford TN24 0LZ, UK
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La Tessa G, Tedeschi E, Covelli E, Pasqualetto L, Cirillo M, Belfiore G. Acute Encephalitis of Unknown Etiology: Early Diagnosis and Follow-up of Disease Evolution. MRI. Neuroradiol J 2006; 19:313-21. [DOI: 10.1177/197140090601900307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 05/11/2006] [Indexed: 11/17/2022] Open
Abstract
Two women with viral encephalitis of unknown etiology were studied with serial MR studies at 1.5 Tesla using: Spin-Echo (SE) T1-weighted (T1w) sequences before and after i.v. administration of paramagnetic contrast agent, with/without magnetization transfer (MT), Fast SE and Fluid-attenuated Inversion Recovery (FLAIR) T2-weighted sequences, Echo-Planar Single-Shot sequences for the assessment of water diffusivity (Diffusion Weighted, DW, and Apparent Diffusion Coefficient maps, ADC). The DW and T1w sequences with MT after contrast were most useful to detect the initial pathologic alterations, thereby reinforcing the clinical diagnostic hypothesis and prompting appropriate drug treatment, even if the laboratory data were not conclusive for viral etiology. In a later phase, both cases showed MR evidence of lacunar foci in the grey matter, and cortical laminar necrosis, probably indicating a concomitant hypoxic/ischemic mechanism.
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Affiliation(s)
| | - E. Tedeschi
- Dipartimento di Diagnostica per Immagini, AORN S. Sebastiano, Caserta
| | - E.M. Covelli
- Dipartimento di Diagnostica per Immagini, AORN S. Sebastiano, Caserta
| | | | - M. Cirillo
- Cattedra di Neuroradiologia, II Università degli Studi di Napoli; Italy
| | - G. Belfiore
- Dipartimento di Diagnostica per Immagini, AORN S. Sebastiano, Caserta
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