Abstract
Background:Herpes simplex virus encephalitis (HSVE) is the most morbid clinical syndrome associated with the human herpes virus. Despite treatment with appropriate dosages of acyclovir, neurologic relapse of HSV infection have been reported after cranial surgery. Rarely, neurological deterioration due to postinfectious inflammatory response without demonstrable HSV reactivation may recur following cranial surgery.Case Description:We report a case of a 17-year-old girl who presented with a HSVE relapse on the 6th postoperative day following resective surgery for medically refractory epilepsy and review the literature. Postinfectious inflammatory reaction may be the underlying mechanism in cases with no HSV identified on cerebrospinal fluid (CSF) or brain polymerase chain reaction (PCR), such as in the current case.Conclusion:HSVE must be suspected in patients with previous history of HSVE and postoperative fever associated with an altered state of consciousness and/or seizures. Considering the high mortality and morbidity rates associated with HSVE, an adequate prophylactic administration of acyclovir should be considered for patients with previous history of HSVE undergoing neurosurgical procedures, especially when surgery involves the site of a previous herpetic lesion.
Highlights
Herpes simplex virus encephalitis (HSVE) is the most morbid clinical syndrome associated with the human herpes virus
Herpes simplex virus encephalitis (HSVE), mostly caused by herpes simplex virus type 1 (HSV‐1), is the most morbid clinical syndrome associated with the human herpes virus
We report a case of a 17‐year‐old girl who presented with presumed postinfectious immune‐inflammatory relapse following resective surgery for medically refractory epilepsy, review the literature and provide recommendations for management
Summary
HSVE must be suspected in patients with previous history of HSVE and postoperative fever associated with an altered state of consciousness and/ or seizures. The cause of the fever and seizures was unclear, but Figure 1: Preoperative axial T2WI MRI showing encephalomalacia involving the anterior and mesial aspect of the right temporal lobe, right frontal operculum, and right insula a b c. On the 12th POD, the patient became hemodynamically and respiratory unstable, requiring sedation, intubation, and ventilator support for 6 days Thereafter, she had with progressive improvement of fever and seizures, but cognitive deterioration and new onset left hemiparesis persisted. MRI performed 1‐month following surgery revealed persistent changes of the right hemisphere and left frontal lobe [Figure 4]. At follow‐up 1 year after surgery in an outpatient clinic, the patient is seizure‐free She has left hemiparesis, severe difficulty in swallowing requiring jejunostomy tube, dysphasia, and flat affect. She has mild behavioral impairment and emotional lability http://www.surgicalneurologyint.com/content/6/1/47 manifested by fluctuations in level of cooperation from quiet and smiling to marked irritability
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