A rare case of concurrent herpes simplex encephalitis and glioblastoma multiforme

Abstract

Herpes encephalitis superimposed on an intracranial malignancy has previously been described mainly in the context of malignancy imitating infection or in the postoperative setting after neurosurgical intervention. We report a rare case of de novo presentation of concurrent herpes encephalitis and glioblastoma. A 63-year-old man presented with status epilepticus and subsequent magnetic resonance imaging (MRI) brain showed a right temporal enhancing lesion with mass effect. He underwent a craniotomy and debulking of this lesion, which on subsequent histology was positive for herpes simplex virus (HSV) antigens and HSV DNA was confirmed by polymerase chain reaction analysis. The sample however also had some hypercellular areas with atypical astrocytes. Our patient recovered well from surgery and was eventually commenced on acyclovir albeit with a delay of 3 weeks due to the initial diagnostic dilemma. However, he re-presented with lethargy and confusion a further 3 weeks later and an MRI scan showed recurrence of the temporal lesion with MR spectroscopy more suggestive of high-grade glioma. He, therefore, underwent a further debulking surgery and the histology revealed a WHO Grade 4 glioblastoma with some residual areas of inflammation. A diagnosis of 2 co-existing pathologies namely HSV encephalitis and glioblastoma was thus reached. Unfortunately, due to poor performance status, he could not undergo chemo-radiotherapy and died 8 months after presentation. Immuno-modulators, expressed locally and globally in glioma patients, are likely to render them susceptible to infections. There are an increasing number of reports of HSV encephalitis in the glioma setting postoperatively. However, we report a de novo presentation which has only been recognized once before in the 1970s. Recognition of HSV encephalitis in glioma patients in the de novo and also the postoperative context is important for commencing early treatment and preventing poor outcomes.

HSV-Encephalitis Reactivation after Cervical Spine Surgery

“…The outcomes of elderly patients also could present a higher possibility of comorbidities; however, several cases report complete recovery from HSVE following neurosurgery ([7]; Pena 1987; Koskiniemi 1996). Though age may affect the diagnostic tests used and recovery, the accuracy and speed of treatment following initial symptoms are the best predictors of clinical outcomes [5, 7, 25]. Our case is a unique contribution to the literature because it demonstrates a presumed case of HSV and resultant herpes encephalitis with no significant MRI findings in the setting of recent intradural cervical spinal surgery, an event not previously reported in the literature.…”

“…Although we present a case of a 78-year-old patient, aspects of prognosis and morbidity may differ between populations of patients [5, 20]. The literature suggests a tendency to affect “frail subjects, with peaks in the elderly and pediatric populations [5, 24, 25]”; hence, a high index of suspicion should be considered for those at high risk. A systematic review of the literature on patients undergoing surgery for degenerative cervical myelopathy suggests that though duration and severity of symptoms related to neurological procedures are more closely associated with surgical outcomes, elderly patients and positive smoking status may have predictive value for comorbidities following surgery [7].…”

Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature

“…19,36 Seven of these patients underwent decompressive craniectomy or temporal lobectomy in part because of persistent status epilepticus, 18,29,44,46,[63][64][65] with good functional outcomes and seizure resolution in 3 cases. 29,44,63 Notably, nearly all surgical patients with HSVE-associated seizures reported in the literature displayed additional evidence of severely elevated ICP before undergoing surgery. 8,[16][17][18][19][20]23,25,27,29,32,36,37,[41][42][43][44][45][46]50,52,58,64,65 Only one report in this review described ATL specifically to control medically refractory status epilepticus in a patient with acute HSVE.…”

“…8,52 Ten patients developed status epilepticus associated with HSVE. 19,36 Seven of these patients underwent decompressive craniectomy or temporal lobectomy in part because of persistent status epilepticus, 18,29,44,46,[63][64][65] with good functional outcomes and seizure resolution in 3 cases. 29,44,63 Notably, nearly all surgical patients with HSVE-associated seizures reported in the literature displayed additional evidence of severely elevated ICP before undergoing surgery.…”

Herpes simplex reactivation following neurosurgery: case report and review of the literature

“…In our review of 40 cases of postoperative neurosurgical patients with HSV diagnosis following craniotomy, 12 (30%) patients died and 1 had unreported outcome due to hospital transfer. [1][2][3][4][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]26,[30][31][32][33][34][35][36] Fever, headache, and altered mental status were common presenting symptoms and started anywhere from POD 1 to POD 90, with a majority occurring in a delayed fashion between PODs 7 and 12. 1-4, 6-24, 26, 30-36 Surgical site varied and does not alone explain potential reactivation of HSV, although it is unknown how many of these patients received perioperative steroids.…”