Diagnosis Of Herpes Simplex Encephalitis Research Articles

Acyclovir-Responsive Glioma: The Need for Vigilant Diagnosis

We report a case of an acyclovir-responsive glioma, which was initially misdiagnosed as herpes simplex encephalitis (HSE). Intravenous acyclovir alone, without corticosteroid, dramatically improved the patient’s symptoms and magnetic resonance imaging findings. He developed headache and amnesia after 1 year, when the stereotactic brain biopsy confirmed the final diagnosis of a glioblastoma, isocitrate dehydrogenase-1 wild-type. In retrospect, some of his sero-radiologic findings were not consistent with HSE. Polymerase chain reaction for herpes simplex virus in the cerebrospinal fluid tested negative. Parieto-occipital involvement and absence of post-treatment atrophy were also signs against HSE. We suggested that a low-grade glioma was present from the beginning and later underwent malignant transformation. The diagnosis of HSE should be made carefully. Acyclovir might also work on gliomas; this is confirmed by a typical clinical picture of HSE and a clear acyclovir-response. A vigilant review of the paraclinical features may shed light on the correct diagnosis. Key words: Encephalitis, herpes simplex; Glioblastoma; Neuroimaging; Neuropathology

Nadir Bir Olgu: Herpes Simpleks Ensefaliti

Herpes Simplex Encephalitis (HSE) is one of the most common causes of sporadic encephalitis and has the most mortal progression. A 22-year-old female patient applied to the emergency department with nausea and vomiting that lasted three days. The patient Cerebrospinal Fluid (CSF) was clear, the glucose ratio was low, and the protein ratio was high in the Lumbar Puncture (LP). HSV-DNA tests were requested with CSF culture and Polymerase Chain Reaction (PCR). Based on the LP results, and considering viral encephalitis, acyclovir treatment was started. The patient died on the 5th day while her treatment was continuing. HSV-DNA with PCR in BOS is the gold standard for the diagnosis of HSE. The most effective agent in treatment is acyclovir. The prognosis of the disease is poor.

Role of 3D Pseudocontinuous Arterial Spin-Labeling Perfusion in the Diagnosis and Follow-Up in Patients with Herpes Simplex Encephalitis.

Early diagnosis and treatment of herpes simplex encephalitis are crucial to reduce morbidity and mortality. Our aim was to investigate the role of 3D pseudocontinuous arterial spin-labeling in herpes simplex encephalitis. From 2014 to 2019, seventeen consecutive patients with herpes simplex encephalitis and 15 healthy volunteers were recruited in the study. Conventional MR imaging and 3D pseudocontinuous arterial spin-labeling were performed in all subjects. According to the disease duration, the lesions were classified into 3 groups, including acute, subacute, and chronic stages, respectively. Clinical, neuroradiologic, and follow-up features were studied. The normalized lesion/normal tissue CBF values of lesions at different stages were measured and compared with those in the control group, respectively. Compared with the control group, herpes simplex encephalitis demonstrated hyperperfusion in 11 acute cases and 6 subacute cases and hypoperfusion in 6 chronic cases. The mean normalized lesion/normal tissue CBF values of the lesions were 2.68 ± 0.54 in the acute stage, 2.42 ± 0.52 in the subacute stage, and 0.87 ± 0.30 in the chronic stage, respectively. The mean normalized lesion/normal tissue CBF values of acute and subacute lesions were significantly higher than those of the control group (1.33 ± 0.08; P < .001, respectively), while the mean normalized lesion/normal tissue CBF values of chronic lesions were lower than those of the control group (P < .05). Gradual perfusion reduction on serial 3D pseudocontinuous arterial spin-labeling was observed in herpes simplex encephalitis after effective therapy. Conventional MR imaging remains most helpful in the diagnosis of herpes simplex encephalitis, while 3D pseudocontinuous arterial spin-labeling could be an adjunctive technique by providing dynamic CBF features at different stages in herpes simplex encephalitis.

ABSENT MRI FINDING OF HERPES SIMPLEX VIRAL EECEPHALITIS IN RENAL TRANSPLANT PATIENT

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Herpes simplex viral encephalitis (HSVE) is typically associated with a constellation of frontotemporal features and MRI findings showing increased signal intensity in the temporal lobe, with characteristic sparing of the lentiform nuclei. We report a case of HSVE with profound neurological manifestations without MRI findings in an immunosuppressed adult after kidney transplant. CASE PRESENTATION: 58 year old man with history of renal transplant in 2012 presented with profound ataxia, generalized fatigue for 3 days. He was compliant with Tacrolimus and Mycophenolate without any adverse events. On physical exam the patient was afebrile, normotensive with temporal wasting. His neurological, cardiovascular, chest and abdominal examination were benign. CT head was unremarkable. CT abdomen/pelvis/chest showed numerous hepatic cysts, and transplanted kidney. During the hospitalization he had no resolution of symptoms and had a seizure requiring intubation for airway protection. He was empirically started on Vancomycin and Meropenem . MRI head on day 4 was unremarkable. Tacrolimus level was therapeutic. LP was performed and showed lymphocytic pleocytosis CSF and elevated protein with high RBC count 70. The patient was started on ganciclovir for high clinical suspension of HSV or CMV encephalitis. EEG was abnormal with severe diffuse background slowing. After initiation of antiviral therapy pt demonstrated marked clinical improvement. CSF analysis revealed a positive HSV–2 PCR. The patient was successfully extubated and completed a course of oral acyclovir. DISCUSSION: HSVE is a neurological emergency with high morbidity and mortality. It is caused by herpes simplex virus type one (90%), followed by type two (10%). The presentation is usually nonspecific and may include acute febrile illness with headache, progressive altered mental status, hemiparesis, and seizures. In the immunocompetent adult patient, the pattern is quite typical and MRI usually shows bilateral asymmetrical involvement of the limbic system, medial temporal lobes, and inferolateral frontal lobes. The basal ganglia are typically spared. In immunocompromised patients, involvement can be more diffuse, and more likely to involve the brainstem, but normal MRI findings is highly unusual in HSVE. Our case reinforces the importance of consideration of HSVE in the differential of patient's with suggestive clinical features even with absent MRI finding. CONCLUSIONS: As clinicians, our index of suspicion should remain high in patients presenting with the typical features of encephalitis such as fever, headache, confusion, and clouding of consciousness. Although this case was not a classic presentation for HSVE and MRI was unremarkable, neurologic manifestations in an immunosuppressed host should prompt further exploration. The diagnosis of HSVE is usually established from the combination of the clinical and investigative features. Reference #1: Kaya A, Mert A, et al. Herpes simplex virus encephalitis: clinical manifestations, diagnosis and outcome in 106 adult patients. Sili U, J Clin Virol. 2014;60:112–118. Reference #2: Bulakbasi N, Kocaoglu M Central nervous system infections of herpesvirus family. Neuroimaging Clin N Am. 2008;18:53–84. Reference #3: Croll, Benjamin J et al. “MRI diagnosis of herpes simplex encephalitis in an elderly man with nonspecific symptoms” Radiology case reports vol. 12,1 159-160. 22 Dec. 2016, https://doi.org/10.1016/j.radcr.2016.11.021 DISCLOSURES: No relevant relationships by Mona Alipour, source=Web Response no disclosure on file for Farhad Arjomand; no disclosure on file for Louis Gerolemou; No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Jose Orsini, source=Web Response Speaker/Speaker's Bureau relationship with Allergan Please note: $20001 - $100000 Added 03/18/2019 by Joshua Rosenberg, source=Web Response, value=Honoraria No relevant relationships by Sahar Takkouche, source=Web Response

335. Missed and Delayed Diagnosis of Herpes Simplex Encephalitis in Inpatient and Ambulatory Care Settings

BackgroundHerpes simplex encephalitis (HSE) is a severe, and often fatal, condition requiring timely diagnosis and treatment. Little is known about the frequency and factors associated with diagnostic delays.MethodsWe conducted a retrospective cohort study using the Truven Health Analytics Commercial Claims and Encounters Database from 2011 to 2016. We identified case visits where patients were first diagnosed with HSE. We analyzed visits prior to the index HSE diagnosis for HSE-related symptoms, including fever, headache, seizure, neurologic disorder, or impaired consciousness. We utilized a time-series change-point analysis and simulation models to identify the window before an HSE diagnosis where diagnostic opportunities began to appear and to estimate the likelihood of actual diagnostic delays.ResultsOur study cohort included 3,390 cases of HSE. There is a dramatic spike in visits with HSE-related symptoms that occurs just prior to the index HSE diagnosis (see figure). Prior to the index diagnosis we identified 2,459 visits, from 938 patients, that contained possible symptoms of HSE. We estimated that approximately 1,355 (CI 1,195–1,490) visits represented likely diagnostic delays with around 20% (CI 18.8–21.0) of patients experiencing at least one missed opportunity. The median duration of diagnostic delays, from first symptoms to diagnosis, was 6 days. Most diagnostic opportunities occurred in outpatient settings, 835 delays (CI 739–944), followed by emergency departments, 313 delays (CI 252–354), and inpatient settings, 259 (CI 226–291). Diagnostic opportunities involving seizures tended to occur earliest (median 7 days before HSE diagnosis), followed by headaches, neurologic symptoms, or changes in mental status (5 days), and finally fever (3 days). Patients with a history of three or more visits for chronic migraines, 90 days before HSE, were more likely to experience a diagnostic delay, OR 2.5 (CI 1.4–3.1), and experienced more diagnostic delays 0.8 vs. 1.5 delays (P < 0.001).ConclusionThere may be many missed diagnostic opportunities in both inpatient and ambulatory settings. Diagnostic opportunities tended to present with neurologic conditions before fever. Most opportunities occur in outpatient and emergency settings. Patients with a history of migraines may be more at risk for experiencing a delay. Disclosures All authors: No reported disclosures.

Predominant area of brain lesions in neonates with herpes simplex encephalitis.

Nonspecific manifestations and a varied distribution of brain lesions can delay the diagnosis of herpes simplex encephalitis (HSE) in neonates. The aim of this study was to report predominant brain lesions in neonatal HSE, and then to investigate the association between pattern of predominant brain lesions, clinical variables and neurodevelopmental outcome. A multicenter retrospective study was performed in neonates diagnosed with HSE between 2009 and 2014. Magnetic resonance (MR) images, including diffusion-weighted images, were obtained in the acute and chronic phase. Three predominant areas of brain injury could be defined based on characteristic MRI findings in 10 of the 13 infants (77%). The inferior frontal/temporal pole area was involved in five (38%) patients. The watershed distribution was present in six (46%) patients. Four (31%) infants involved the corticospinal tract area. No significant association was found between any predominant distribution of brain lesion pattern and sex, country, viral type or viral load. However, the corticospinal tract involvement was significantly associated with motor impairment (P=0.045). Three predominant areas of brain lesion could be recognized in neonatal HSE. Recognition of those areas can improve prediction of neurodevelopmental outcome.

Incidence and mortality of herpes simplex encephalitis in Denmark: A nationwide registry-based cohort study

We aimed to investigate the incidence and mortality of herpes simplex encephalitis (HSE) in a nationwide cohort. From the Danish National Patient Registry, we identified all adults hospitalised with a first-time diagnosis of HSE in Denmark during 2004-2014. The HSE diagnoses were verified using medical records and microbiological data. Patients were followed for mortality through the Danish Civil Registry System. We estimated age-standardised incidence rates of HSE and 30-day, 60-day, and 1-year cumulative mortality. Furthermore, we assessed whether calendar year, age, gender, level of comorbidity, virus type, and department type was associated with HSE mortality. We identified a total of 230 cases of HSE. Median age was 60.7 years (interquartile range: 49.3-71.6). The overall incidence rate was 4.64 cases per million population per year (95% confidence interval: 4.06-5.28). The cumulative mortality within 30 days, 60 days, and 1 year of the HSE admission was 8.3%, 11.3%, and 18.6%, respectively. Advanced age and presence of comorbidity were associated with increased 60-day and 1-year mortality. This nationwide study of verified HSE found a higher incidence than reported in previous nationwide studies. Presence of comorbidity was identified as a novel adverse prognostic factor. Mortality rates following HSE remain high.

Validity of the coding for herpes simplex encephalitis in the Danish National Patient Registry.

BackgroundLarge health care databases are a valuable source of infectious disease epidemiology if diagnoses are valid. The aim of this study was to investigate the accuracy of the recorded diagnosis coding of herpes simplex encephalitis (HSE) in the Danish National Patient Registry (DNPR).MethodsThe DNPR was used to identify all hospitalized patients, aged ≥15 years, with a first-time diagnosis of HSE according to the International Classification of Diseases, tenth revision (ICD-10), from 2004 to 2014. To validate the coding of HSE, we collected data from the Danish Microbiology Database, from departments of clinical microbiology, and from patient medical records. Cases were classified as confirmed, probable, or no evidence of HSE. We estimated the positive predictive value (PPV) of the HSE diagnosis coding stratified by diagnosis type, study period, and department type. Furthermore, we estimated the proportion of HSE cases coded with nonspecific ICD-10 codes of viral encephalitis and also the sensitivity of the HSE diagnosis coding.ResultsWe were able to validate 398 (94.3%) of the 422 HSE diagnoses identified via the DNPR. Hereof, 202 (50.8%) were classified as confirmed cases and 29 (7.3%) as probable cases providing an overall PPV of 58.0% (95% confidence interval [CI]: 53.0–62.9). For “Encephalitis due to herpes simplex virus” (ICD-10 code B00.4), the PPV was 56.6% (95% CI: 51.1–62.0). Similarly, the PPV for “Meningoencephalitis due to herpes simplex virus” (ICD-10 code B00.4A) was 56.8% (95% CI: 39.5–72.9). “Herpes viral encephalitis” (ICD-10 code G05.1E) had a PPV of 75.9% (95% CI: 56.5–89.7), thereby representing the highest PPV. The estimated sensitivity was 95.5%.ConclusionThe PPVs of the ICD-10 diagnosis coding for adult HSE in the DNPR were relatively low. Hence, the DNPR should be used with caution when studying patients with encephalitis caused by herpes simplex virus.

Genital herpes and encephalitis; a case history

A 19-year-old, previously healthy unmarried girl presented with sudden onset loss of consciousness preceded by genital ulcers, fever and headache. Examination revealed mild neck stiffness, 4/15 of GCS, and upper motor neuron signs in all four limbs. In addition, there were multiple, superficial and tender genital ulcers. Electro Encephalogram (EEG) showed evidence of encephalitis and subsequent serological tests revealed presence of HSV antibodies. Her condition improved remarkably following intravenous Aciclovir therapy. Presence of typical herpetic ulcers, positive type specific serology test for HSV, evidence of encephalitis in the EEG and good response to Aciclovir, favoured the possible diagnosis of Herpes Simplex Encephalitis (HSE). Sri Lanka Journal of Sexual Health and HIV Medicine Vol.1 2015: 29-32

Post-operative Herpes Simplex Virus Encephalitis after Surgical Resection of Meningioma: A Case Report and Review of the Literature

Background: Herpes Simplex Virus (HSV) encephalitis is a rare but life threatening complication in neurosurgical patients. Diagnosis of Herpes Simplex Encephalitis (HSVE) is based on the detection of the herpes simplex virus (HSV) DNA in patient`s CSF samples. A low threshold for both investigations with CSF PCR and empirical treatment with intravenous acyclovir is warranted. Methods and materials: In this case we discussed a 55- year-old man with HSVE after surgical resection of meningioma. We represent a rare case of HSV encephalitis. The appearance of a high grade fever (40°C) and altered consciousness and spastic quadriparesia complicated the post-operative course in a 55-year-old man who underwent surgical removal of a meningioma on the second postoperative day. Brain MRI detected brain abnormalities on the fourth day after onset of symptoms, and polymerase chain reaction (PCR) identification of HSV 1 DNA confirmed the diagnosis. Result: A positive prognosis was achieved due to the decision to start specific, high-dose antiviral therapy based on clinical suspicion, before a firm diagnosis was established. . Treatment with acyclovir was maintained for 8 weeks and patient die after severe sepsis. Conclusion: There are only few case reports of postoperative HSV1 encephalitis. These reports suggest that this rare postoperative complication is associated with a poor prognosis, with high mortality and morbidity. Neurosurgical interventions involving peripheral nerve root or ganglia have been reported to cause re-activation of cutaneous herpes simplex infection. Factors compromising the immune system may also increase susceptibility to herpes simplex infection.

Cranial CT/MRI findings in children with acute herpes simplex encephalitis

In this study, cranial computerized tomography (CT) and/or magnetic resonance imaging (MRI) findings were investigated in nine children with acute herpes simplex encephalitis (HSE). HSE was confirmed by polymerase chain reaction. Our purpose was to evaluate the diagnostic value of CT and MRI in the diagnosis of HSE and to determine the widespread of the cranial abnormalities in HSE in childhood. Cranial CT was examined in all children and found to be normal in four children. Cranial MRI was examined in seven children, of whom, three was normal. Temporal involvement was diagnosed in only two children. Our findings revealed that the range of cranial involvement was fairly variable in childhood HSE; aside from typical temporal involvement, cranial images may be normal or widespread involvement including basal ganglia, thalamus, frontal and parietal lobes may be seen in children with HSE.

Update on Herpes Simplex Encephalitis

Herpes simplex encephalitis (HSE), which is caused by the herpes simplex virus (HSV), is a severe neuro-infectious disease characterized by high mortality and morbidity. We reviewed the pathomechanism, diagnosis, and treatment of HSE based on recent progress in the field. The highlighted mechanism of HSE in this review is immune-mediated tissue damage caused by host immunity. Major symptoms of HSE include psychiatric alteration, Klüver-Bucy syndrome, and amnesia, caused by frequent involvement of the limbic system. An important differential diagnosis of HSE is autoimmune limbic encephalitis, including anti-N-methyl-D-aspartate receptor encephalitis, and anti-voltage-gated K⁺ channel encephalitis. HSE is definitely diagnosed based on the detection of HSV-DNA by polymerase chain reaction and/or the detection of HSV-IgG antibody in the cerebrospinal fluid (CSF). Repeated CSF examinations are required for the accurate diagnosis of HSE. Acyclovir (ACV) plays a central role in the treatment of HSE, and its early initiation is essential for good outcome in patients with HSE. Acute administration of corticosteroids for HSE is controversial; a randomized, double-blind, placebo-controlled trial to investigate the efficacy of add-on corticosteroids to ACV is ongoing.

Early diagnosis of herpes encephalitis saves lives: A case report

Herpes simplex virus (HSV) is the most important pathogen causing endemic encephalitis. HSV-1 is responsible for 90% of the cases which is the only treatable viral encephalitis. Clinically it is characterized by decreased level of consciousness, changes in personality, convulsions, and focal neurological deficits. Diagnosis of HSV encephalitis is made by detection of HSV DNA in the cerebrospinal fluid via polymerase chain reaction (PCR) method. The mortality rate in untreated HSV encephalitis is 50-70%. In this paper a patient diagnosed as Herpes simplex encephalitis according to positive PCR, clinic findings, radiological imaging and electroencephalogram (EEG). The patient was successfully treated for 21 days with acyclovir without any complication. This case report emphasizes the value of early diagnosis and treatment.

Electroencephalography as an Adjunct in the Diagnosis of HSV Encephalitis in Preterm Twins.

Neonatal herpes simplex virus (HSV) infections are rare, with an estimated 1500 cases diagnosed annually in the United States.1 Intrapartum exposure to HSV in vaginal secretions leads to 85% of neonatal HSV infections, while intrauterine and postpartum infection accounts for 5% and 10% of infections, respectively.2 Irrespective of the route of exposure, neonatal HSV infection can cause devastating disease if not recognized and treated early.3 Primary maternal HSV infections carry a considerably higher risk of vertical transmission compared with reactivated latent infection or asymptomatic viral shedding because of the higher titer of virus found in the maternal genital track and the lack of transplacental transfer of protective IgG to the fetus.2 Other important risk factors for transmission include prolonged rupture of membranes, which increases the likelihood of ascending infection, and the use of intrapartum fetal scalp monitoring.2 Neonatal disease is classified as cutaneous/mucosal, central nervous system (CNS; with an encephalitic presentation), or disseminated disease involving multiple organs with or without CNS involvement.3 CNS and disseminated disease have the highest risk of morbidity and mortality, and favorable clinical outcomes are more likely if intravenous acyclovir is started promptly.2,3 However, treatment is frequently delayed because the presenting symptoms of neonatal HSV infection are often nonspecific. Despite decades of research there has not been a significant shortening of the time to institution of therapy.3 Because of the potentially devastating consequences of neonatal HSV infection, many researchers have evaluated screening of pregnant women for HSV infection and third trimester prophylaxis of HSV-positive women. Unfortunately, serological screening of pregnant women is of little use in preventing neonatal HSV infection because seropositivity does not predict the presence of infectious virus in the genital secretions of pregnant women at the time of parturition.4 Likewise, antenatal surveillance cultures to detect HSV in maternal genital secretions had poor correlation with the presence of infectious virus at the time of delivery.5 Third trimester prophylaxis has been demonstrated to reduce the incidence of genital lesions in pregnant women at delivery, the detection of HSV in genital secretions, and the rate of Caesarean delivery; however, the evidence is insufficient to support a recommendation for prophylaxis of pregnant women.6 It should be kept in mind as well that Caesarean delivery does not eliminate the risk of neonatal HSV infection, and in the setting of premature or prolonged rupture of membranes may provide little benefit.7 Because of the diagnostic uncertainty and the lack of effective preventive measures, some researchers support the use of acyclovir along with empiric broad-spectrum antibiotics for infants undergoing a rule out sepsis workup, though to date no standard of care has been defined.1 The cases described here illustrate the diagnostic uncertainty posed by neonatal HSV encephalitis. We propose an evidence-based application of routine electroencephalography (EEG) to aid in the workup of equivocal cases.

Development history of herpes simplex encephalitis

Herpes simplex encephalitis (HSE) is an acute central nervous system infection caused by herpes simplex virus (HSV). Early clinical manifestations mainly include fever, headache and unconsciousness; when progressing, psychiatric symptoms can occur. Death or serious neurological sequelae will happen if not treated. With the development of laboratory tests and imaging techniques, the early diagnosis of HSE is possible. Even though imaging with temporal lobe abnormal signal has the implication to HSE, the application of polymerase chain reaction (PCR) in detecting HSV DNA in cerebrospinal fluid is currently the gold standard to diagnose HSE. Once diagnosed, acyclovir must be given as soon as possible, as delayed treatment will result in a poor outcome. doi: 10.3969/j.issn.1672-6731.2014.08.003

Herpes simplex encephalitis: clinical presentation, neurological sequelae and new prognostic factors. Ten years of experience

Herpes simplex encephalitis (HSE) is the most important viral encephalitis due to its high mortality and neurological sequelae. The aim of this study was to contribute to better characterise the HSE. We retrospectively analysed patients with a diagnosis of HSE in our hospital during 2000 and 2010. We included those patients who had a positive result for PCR for herpes simplex virus in cerebrospinal fluid and those with a negative result presenting with a consistent clinical and neuroimage profile. We included 26 patients (10 men, 16 women). Mean age was 58 years. Most frequent symptoms at admission were fever, confusion, aphasia and seizures. Mortality rate was 11 %. 2 patients presented a clinical relapse. In conclusion, the most frequent neurological sequelae were aphasia and amnesia. Disorientation, hyponatremia and abnormalities in initial brain CT were identified as new prognostic factors.

Pitfalls associated with the diagnosis of herpes simplex encephalitis

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.

Mesiotemporal changes on magnetic resonance imaging in neurosyphilis

We report a case of neurosyphilis with magnetic resonance imaging (MRI) brain scan findings compatible with a diagnosis of herpes simplex encephalitis with negative testing for herpes simplex virus in the cerebral spinal fluid. An extensive review of the literature has been undertaken revealing 24 cases worldwide where there are mesiotemporal changes on MRI concurrent with a diagnosis of neurosyphilis. Therefore, it is now well established that neurosyphilis, 'the great imitator', should be considered in the differential diagnosis in all patients demonstrating mesiotemporal changes on MRI, changes usually seen in herpes simplex encephalitis.

Delays in Initiation of Acyclovir Therapy in Herpes Simplex Encephalitis

Diagnosis of herpes simplex encephalitis (HSE) is based on clinical findings, MRI, and detection of herpes simplex virus (HSV) DNA in cerebrospinal fluid (CSF) using polymerase chain reaction amplification. Delays in starting treatment are associated with poorer clinical outcomes. We assessed the timing of initiation of acyclovir therapy in HSE. Inpatient databases from seven hospitals in Winnipeg, Manitoba were used to identify individuals diagnosed with encephalitis and HSE from 2004 to 2009. The time taken to initiate therapy with acyclovir and the reasons for delays were determined. Seventy-seven patients were identified; 69 (90%) received acyclovir; in the others a non-HSV infection was strongly suspected. Thirteen patients were subsequently confirmed to have HSE. Acyclovir was initiated a median of 21 hours (3-407) after presentation in encephalitis cases, and a median of 11 hours (3-118) in HSE. The most common reason for delay was a failure to consider HSE in the differential diagnosis, despite suggestive clinical features. Where therapy was delayed in HSE patients, the decision to begin acyclovir was prompted by transfer of the patient to a different service (55%), recommendations by consultants (18%), imaging results (18%), and CSF pleocytosis (9%). Delays in initiating acyclovir for HSE are common, and are most often due to a failure to consider HSE in a timely fashion on presentation. In order to improve patient outcomes, physicians should be more vigilant for HSE, and begin acyclovir therapy expeditiously on the basis of clinical suspicion rather than waiting for confirmatory tests.

An Unusual Presentation of Herpes Simplex Virus Encephalitis

We present a case of a 65-year-old man with an acute alteration in mental state that was initially diagnosed as a functional psychiatric condition. After extensive workup, herpes simplex virus type 1 (HSV-1) was detected in the patient's cerebrospinal fluid (CSF) by polymerase chain reaction (PCR), and he responded rapidly to treatment with acyclovir. The case illustrates the importance of actively excluding organic causes in such patients, the need to have a low threshold of suspicion for HSV encephalitis, and the central role of CSF PCR testing for the diagnosis of HSV encephalitis, even in the absence of CSF biochemical abnormalities.