Atypical case of Herpes simplex encephalitis

Auyeung, P.; Dunn, Arthur D.

doi:10.1111/j.1445-5994.2008.01645.x

Cited by 10 publications

(7 citation statements)

References 8 publications

(11 reference statements)

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“…The occurrence of HSV-1 encephalitis in immunocompromised patients has rarely been reported. Classic clinical presentations with atypical laboratory studies have been described in a patient with metastatic colon cancer four weeks after receiving chemotherapy [2], three patients who were immunosuppressed with either Hodgkin's or non-Hodgkin's lymphoma [3-5], and another patient with glioblastoma multiforme on dexamethasone [5]. Atypical clinical presentations of HSV encephalitis have been described in patients receiving steroids, and also occur in 2% of patients infected with human immunodeficiency virus (HIV) with neurological symptoms, usually in association with CD4 T cell counts <200 cells/μL [6].…”

Section: Discussionmentioning

confidence: 99%

Subacute herpes simplex virus type 1 encephalitis as an initial presentation of chronic lymphocytic leukemia and multiple sclerosis: a case report

Singhal

Corman

2011

J Med Case Reports

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IntroductionHerpes simplex virus type 1 encephalitis presents acutely in patients who are immunocompetent. We report what we believe to be the first published case of a subacute course of herpes simplex virus type 1 encephalitis in a patient with asymptomatic chronic lymphocytic leukemia who subsequently developed multiple sclerosis.Case presentationA 49-year-old Caucasian woman with a history of fever blisters presented to the emergency department with a history of left temporal headache for four weeks, and numbness of the left face and leg for two weeks. A complete blood count revealed white blood cell count of 11,820 cells/mL, with an absolute lymphocyte count of 7304 cells/mL. The cerebrospinal fluid contained 6 white blood cells/μL, 63 red blood cells/μL, 54 mg glucose/dL, and 49 mg total protein/dL. Magnetic resonance imaging of the brain revealed meningoencephalitis and bilateral ventriculitis. Cerebrospinal fluid polymerase chain reaction for herpes simplex virus type 1 was positive, and the patient's symptoms resolved after ten days of treatment with parenteral aciclovir. Incidental findings on peripheral blood smear and flow cytometry testing confirmed chronic lymphocytic leukemia. One month later, she developed bilateral numbness of the hands and feet; a repeat cerebrospinal fluid polymerase chain reaction for herpes simplex virus type 1 at this time was negative. A repeat magnetic resonance imaging scan showed an expansion of the peri-ventricular lesions, and the cerebrospinal fluid contained elevated oligoclonal bands and myelin basic protein. A brain biopsy revealed gliosis consistent with multiple sclerosis, and the patient responded to treatment with high-dose parenteral steroids.ConclusionHerpes simplex virus type 1 encephalitis is a rare presentation of chronic lymphocytic leukemia. Our patient had an atypical, subacute course, presumably due to immunosuppression from chronic lymphocytic leukemia. This unusual case of herpes simplex virus type 1 encephalitis emphasizes the importance of T cell function in diseases of immune dysregulation and autoimmunity such as chronic lymphocytic leukemia and multiple sclerosis. It raises the question of whether atypical presentations of herpes simplex virus encephalitis warrant deliberations on immunocompetence. The development of multiple sclerosis in our patient so soon after she received treatment for herpes simplex virus type 1 encephalitis raises the possibility that herpes simplex virus type 1 encephalitis in an immunosuppressed patient may trigger multiple sclerosis.

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Section: Discussionmentioning

confidence: 99%

Subacute herpes simplex virus type 1 encephalitis as an initial presentation of chronic lymphocytic leukemia and multiple sclerosis: a case report

Singhal

Corman

2011

J Med Case Reports

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“…The non-specific and varied nature of presentation makes diagnosis of HSE challenging in both adults8 – 11 and children 12. In 1985, before the routine use of PCR for diagnosis and aciclovir for treatment of HSE, Tashjian and Lane presented two cases of patients with the condition whose symptoms were incorrectly attributed to other diagnoses 8.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic delay in a case of herpes simplex encephalitis

Shalchi

Bennett²,

Hargroves³

et al. 2009

Case Reports

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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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“…Retrospective (78) and prospective (79) studies have demonstrated low yield to testing CSF specimens with normal WBC counts and protein levels. While it is tempting to apply these criteria to limit laboratory testing, atypical cases of HSV neurologic infections in the setting of normal CSF cell counts led to concern regarding standardized screening algorithms (80,81).…”

Section: Laboratory Evaluation Pcr Detectionmentioning

confidence: 99%

Infections of the Central Nervous System

Reznicek¹,

Bloch²,

Tang³

2010

Infectious Disease and Therapy

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INTRODUCTIONViral infections of the central nervous system (CNS) often present a diagnostic dilemma. The number of causative agents is vast, much greater than a century ago, when the established etiologies of CNS infections were mainly limited to rabies virus and polio virus. The physical findings of CNS infection are often nonspecific, and initial laboratory results may provide few additional clues as to the etiology. Molecular diagnostic testing has dramatically improved the ability to detect viral CNS infections, but requires expertise in the attributes and limitations of these techniques. Even discriminating infectious from noninfectious causes may be challenging, as metabolic, autoimmune, neoplastic, toxic, and endocrinologic entities may mimic meningitis or encephalitis. CNS infections represent syndromes where close collaboration between clinicians and laboratorians is crucial in providing a rapid diagnostic evaluation and an appropriate interpretation of results.This chapter concentrates on viral infections of the CNS in immunocompetent adults, with a focus on assessment and laboratory evaluation. The close anatomical proximity of meninges and brain parenchyma often blurs the distinction between meningitis and encephalitis, causing an overlap syndrome termed meningoencephalitis. For the purposes of this chapter, meningoencephalitis will be considered a subset of encephalitis, while meningitis will refer to isolated inflammation of the meninges. There is significant geographic variability with respect to the microbiology of CNS infections, and the following discussion will highlight the most significant viral pathogens in the United States. A brief overview of laboratory diagnostic techniques will initially be provided followed by a more detailed discussion specifically relating to the various viral pathogens.

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Atypical case of Herpes simplex encephalitis

Cited by 10 publications

References 8 publications

Subacute herpes simplex virus type 1 encephalitis as an initial presentation of chronic lymphocytic leukemia and multiple sclerosis: a case report

Subacute herpes simplex virus type 1 encephalitis as an initial presentation of chronic lymphocytic leukemia and multiple sclerosis: a case report

Diagnostic delay in a case of herpes simplex encephalitis

Infections of the Central Nervous System

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