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Herpes simplex encephalitis: A recent case
Biomedicine & Pharmacotherapy 64 (2010) 306–307
Point of View
Herpes simplex encephalitis: A recent case Khwaja Sami Alim 1,*, Saba Khwaja Alim 1 Internal medicine, West Valley Medical Center, 1717, Arlington Avenue, Caldwell, ID 83605, USA
A R T I C L E I N F O
Article history: Received 20 April 2009 Accepted 7 October 2009 Available online 14 November 2009 Keywords: Empiric Therapy History taking most important
1. Case presentation A 51-year-old woman presented, complaining of severe headache and photophobia, going on for at least two days. She denied any sick contacts. On physical examination, her vitals were stable with BP 120/64 mmHg, Temperature 98 F, RR 18/mt, PR 72/mt., and she did not have any neck rigidity. CT scan of the head without contrast was normal. Lumbar puncture showed: WBC-177U/L, Lymphocyte-98%, Macrophage-2%, CSF glucose-59 mg%, CSF Protein-109 mg%, RBC-150 U/L. Serology for West Nile virus and Herpes virus were added to the lumbar puncture. 2. Assessment The patient was empirically started on IV acyclovir 10 mg/kg every 8 hours for treatment of possible herpes encephalitis. Over next two days, the patient’s condition markedly improved. Later in the hospital course, the patient’s husband mentioned that the she used to get recurrent herpes zoster infections, and the last infection was not long ago. The following day, a PICC line was placed and the patient was discharged home on IV acyclovir therapy. A couple of days later the serology came back positive for Herpes Simplex Virus-1&2 DNA. A feedback from the primary care physician was that the patient was doing very well, and continued to receive the acyclovir treatment as an outpatient. 3. Treatment Herpes simplex encephalitis is a devastating infection of the central nervous system. Even with the early administration of the * Corresponding author. Tel.: +208 455 3917/252 258 5097; fax: +208 455 3922. E-mail addresses: [email protected], [email protected] (K.S. Alim). 1 Both authors have access to the data and a role in writing the manuscript. 0753-3322/$ – see front matter ß 2009 Published by Elsevier Masson SAS. doi:10.1016/j.biopha.2009.10.004
therapy, nearly two thirds of survivors develop significant neurological deficits [2]. For this reason, empiric therapy with acyclovir must be initiated as soon as the diagnosis is considered. Adults should receive a dose of acyclovir 10 mg/kg IV every 8 hours for a minimum of 14 days. Neonatal HSV CNS infection is less responsive to the therapy, and it is recommended to give acyclovir 20 mg/kg every 8 hours for a minimum of 21 days. Each dose should be infused slowly over 1 hour to minimize the risk kidney dysfunction. Local inflammation and phlebitis can occur, so care must be taken to avoid extravasation. Other complications of acyclovir therapy include thrombocytopenia, gastrointestinal toxicity (nausea, vomiting, diarrhoea), and neuron-toxicity (lethargy, disorientation, confusion, tremors, hallucinations, seizures). Repeating CSF after completing a standard course of acyclovir therapy should be considered. A patient with a persistent positive CSF PCR for HSV after completing a standard course of acyclovir should be treated for additional 7 days, followed by a repeat CSF PCR test.
4. Discussion Herpes simplex virus type 1 (HSV-1) encephalitis is the most common cause of sporadic fatal encephalitis worldwide. It usually presents as rapid onset of fever, headache, seizures, focal neurological signs, and impaired consciousness [1]. Laboratory abnormalities include CSF which typically shows a lymphocytic pleocytosis, increased number of erythrocytes and an elevated protein [3,4]. Low glucose is uncommon and may suggest an alternate diagnosis. Imaging studies include CT scan of the brain. It has 50% sensitivity early in the disease, and the presence of temporal lobe abnormalities is considered a strong evidence of herpes simplex encephalitis and is associated with severe brain damage and poor prognosis [5]. MRI is the most sensitive and specific imaging method for HSV encephalitis, especially in the early stages of the disease, although normal MRI findings have been reported in the setting of the disease [6]. Electroencephalogram shows prominent intermittent high amplitude slow waves (delta and theta slowing), but these are nonspecific findings [7,8]. However, history taking is still one of the most important steps. Conditions that may seem trivial to the patient could hold the clue to the diagnosis and treatment. Like in this patient, recurrent herpes skin infections increased the probability of herpes encephalitis.
K.S. Alim, S.K. Alim / Biomedicine & Pharmacotherapy 64 (2010) 306–307
5. Conflicts of interest None. Funding: None. References [1] Hanley DF, Johnson RT, Whitley RJ. Arch Neurol 1987;44:1289. [2] Whitley RJ, Kimberlin DW. Herpes simplex encephalitis: children and adolescents. Semin Pedoater Infect Dis 2005;16:17.
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[3] Nahmias AJ, Whitley RT, Visintine AN, et al. Herpes simplex virus encephalitis: Laboratory evaluation and their diagnostic significance. J Infect Dis 1982;145:829. [4] Razavi B, Razavi M. Herpes simplex encephalitis: an atypical case. Infection 2001;29:357. [5] Levitz RE. Herpes simplex encephalitis: A review. Heart Lung 1998;27:209. [6] Dominques RB, Fink MC, Tsanaclis AM, et al. Diagnosis of herpes simplex encephalitis by MRI and PCR assay of cerebrospinal fluid. J Neurol Sci 1998;157:148. [7] Rose JW, Stroop WG, Matsuo F, Henkl J. Atypical herpes simplex encephalitis: Clinical, virology and neuropathologic evaluation. Neurology 1992;42:1809. [8] VanLandingham KE, Marsteller HB, Ross GW, Hayden FG. Relapse of herpes simplex encephalitis after conventional acyclovir therapy. JAMA 1988;259: 1051.
Point of View
Herpes simplex encephalitis: A recent case Khwaja Sami Alim 1,*, Saba Khwaja Alim 1 Internal medicine, West Valley Medical Center, 1717, Arlington Avenue, Caldwell, ID 83605, USA
A R T I C L E I N F O
Article history: Received 20 April 2009 Accepted 7 October 2009 Available online 14 November 2009 Keywords: Empiric Therapy History taking most important
1. Case presentation A 51-year-old woman presented, complaining of severe headache and photophobia, going on for at least two days. She denied any sick contacts. On physical examination, her vitals were stable with BP 120/64 mmHg, Temperature 98 F, RR 18/mt, PR 72/mt., and she did not have any neck rigidity. CT scan of the head without contrast was normal. Lumbar puncture showed: WBC-177U/L, Lymphocyte-98%, Macrophage-2%, CSF glucose-59 mg%, CSF Protein-109 mg%, RBC-150 U/L. Serology for West Nile virus and Herpes virus were added to the lumbar puncture. 2. Assessment The patient was empirically started on IV acyclovir 10 mg/kg every 8 hours for treatment of possible herpes encephalitis. Over next two days, the patient’s condition markedly improved. Later in the hospital course, the patient’s husband mentioned that the she used to get recurrent herpes zoster infections, and the last infection was not long ago. The following day, a PICC line was placed and the patient was discharged home on IV acyclovir therapy. A couple of days later the serology came back positive for Herpes Simplex Virus-1&2 DNA. A feedback from the primary care physician was that the patient was doing very well, and continued to receive the acyclovir treatment as an outpatient. 3. Treatment Herpes simplex encephalitis is a devastating infection of the central nervous system. Even with the early administration of the * Corresponding author. Tel.: +208 455 3917/252 258 5097; fax: +208 455 3922. E-mail addresses: [email protected], [email protected] (K.S. Alim). 1 Both authors have access to the data and a role in writing the manuscript. 0753-3322/$ – see front matter ß 2009 Published by Elsevier Masson SAS. doi:10.1016/j.biopha.2009.10.004
therapy, nearly two thirds of survivors develop significant neurological deficits [2]. For this reason, empiric therapy with acyclovir must be initiated as soon as the diagnosis is considered. Adults should receive a dose of acyclovir 10 mg/kg IV every 8 hours for a minimum of 14 days. Neonatal HSV CNS infection is less responsive to the therapy, and it is recommended to give acyclovir 20 mg/kg every 8 hours for a minimum of 21 days. Each dose should be infused slowly over 1 hour to minimize the risk kidney dysfunction. Local inflammation and phlebitis can occur, so care must be taken to avoid extravasation. Other complications of acyclovir therapy include thrombocytopenia, gastrointestinal toxicity (nausea, vomiting, diarrhoea), and neuron-toxicity (lethargy, disorientation, confusion, tremors, hallucinations, seizures). Repeating CSF after completing a standard course of acyclovir therapy should be considered. A patient with a persistent positive CSF PCR for HSV after completing a standard course of acyclovir should be treated for additional 7 days, followed by a repeat CSF PCR test.
4. Discussion Herpes simplex virus type 1 (HSV-1) encephalitis is the most common cause of sporadic fatal encephalitis worldwide. It usually presents as rapid onset of fever, headache, seizures, focal neurological signs, and impaired consciousness [1]. Laboratory abnormalities include CSF which typically shows a lymphocytic pleocytosis, increased number of erythrocytes and an elevated protein [3,4]. Low glucose is uncommon and may suggest an alternate diagnosis. Imaging studies include CT scan of the brain. It has 50% sensitivity early in the disease, and the presence of temporal lobe abnormalities is considered a strong evidence of herpes simplex encephalitis and is associated with severe brain damage and poor prognosis [5]. MRI is the most sensitive and specific imaging method for HSV encephalitis, especially in the early stages of the disease, although normal MRI findings have been reported in the setting of the disease [6]. Electroencephalogram shows prominent intermittent high amplitude slow waves (delta and theta slowing), but these are nonspecific findings [7,8]. However, history taking is still one of the most important steps. Conditions that may seem trivial to the patient could hold the clue to the diagnosis and treatment. Like in this patient, recurrent herpes skin infections increased the probability of herpes encephalitis.
K.S. Alim, S.K. Alim / Biomedicine & Pharmacotherapy 64 (2010) 306–307
5. Conflicts of interest None. Funding: None. References [1] Hanley DF, Johnson RT, Whitley RJ. Arch Neurol 1987;44:1289. [2] Whitley RJ, Kimberlin DW. Herpes simplex encephalitis: children and adolescents. Semin Pedoater Infect Dis 2005;16:17.
307
[3] Nahmias AJ, Whitley RT, Visintine AN, et al. Herpes simplex virus encephalitis: Laboratory evaluation and their diagnostic significance. J Infect Dis 1982;145:829. [4] Razavi B, Razavi M. Herpes simplex encephalitis: an atypical case. Infection 2001;29:357. [5] Levitz RE. Herpes simplex encephalitis: A review. Heart Lung 1998;27:209. [6] Dominques RB, Fink MC, Tsanaclis AM, et al. Diagnosis of herpes simplex encephalitis by MRI and PCR assay of cerebrospinal fluid. J Neurol Sci 1998;157:148. [7] Rose JW, Stroop WG, Matsuo F, Henkl J. Atypical herpes simplex encephalitis: Clinical, virology and neuropathologic evaluation. Neurology 1992;42:1809. [8] VanLandingham KE, Marsteller HB, Ross GW, Hayden FG. Relapse of herpes simplex encephalitis after conventional acyclovir therapy. JAMA 1988;259: 1051.