Diagnostic delay in a case of herpes simplex encephalitis

Shalchi, Zaid; Bennett, Alan H.; Hargroves, David; Nash, James

doi:10.1136/bcr.12.2008.1350

Cited by 6 publications

(4 citation statements)

References 13 publications

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“…However, the basal ganglia are typically spared in HSVE, which helps to distinguish it from an MCA infarction. In their case report, Shalchi, et al also mentioned misdiagnosis of HSVE as an ischemic stroke based on right-sided frontal and temporal hypodensities noted radiologically [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Herpes Simplex Virus Encephalitis: Atypical Presentation as a Right Middle Cerebral Artery Stroke

Shoaib

Kraus

Khan

2018

Cureus

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Herpes simplex virus encephalitis (HSVE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis.We report a case of HSVE presenting as a stroke mimic in a 76-year-old female with a history of atrial fibrillation on warfarin. She was admitted to our medical intensive care unit with intermittent fever, lethargy, and new onset left-sided hemiparesis. A computed tomography (CT) of the head showed a right middle cerebral artery (MCA) acute ischemic stroke with midline shift and a dense right MCA sign. Brain magnetic resonance imaging (MRI) showed evidence of acute stroke with consideration of herpes encephalitis. CSF analysis was positive for herpes simplex virus (HSV) type one. She recovered with high-dose intravenous acyclovir therapy.Our patient was a diagnostic dilemma, initially being diagnosed with an acute ischemic stroke and yet found to have HSVE, which mimicked an acute ischemic stroke. Delay in treatment may result in devastating clinical outcomes that may include severe cognitive, focal neurological deficits, persistent seizures, and even death. This case highlights the importance of a multidisciplinary approach and the need for increased awareness of an atypical presentation of HSVE among emergency physicians, neurologist, intensivists, and radiologists.

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Section: Discussionmentioning

confidence: 99%

Herpes Simplex Virus Encephalitis: Atypical Presentation as a Right Middle Cerebral Artery Stroke

Shoaib

Kraus

Khan

2018

Cureus

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“…Even these patients were all immunocompromised, as most other single patients reported earlier. [411121314151617] In all patient despite normal CSF cell count, test on HSV-1 by PCR assay was positive as reported by Jakob, et al .,[11] However, even PCR assay can be negative, leading to premature termination of antiviral treatment. [16]…”

Section: Discussionmentioning

confidence: 68%

Pitfalls associated with the diagnosis of herpes simplex encephalitis

Vachalová

Kyavar

Heckmann

2013

Journal of Neurosciences in Rural Practice

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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.

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“…AbdulJabbar and colleagues describe acute onset hemiparesis in a 17-year-old girl which preceded fever, altered mental status, and seizures by one week due to HSVE [ 12 ]. Still others have described a case of fever, headaches, and altered mental status for approximately 1 week, misdiagnosed as an ischemic stroke based on right sided frontal and temporal hypodensities noted radiologically and later found to have HSVE [ 13 ].…”

Section: Discussionmentioning

confidence: 99%

Herpes Simplex Viral Encephalitis Masquerading as a Classic Left MCA Stroke

Abdelmalik

Ambrose

Bell

2015

Case Reports in Neurological Medicine

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Objective. Stroke is a clinical diagnosis, with a history and physical examination significant for acute onset focal neurological symptoms and signs, often occurring in patients with known vascular risk factors and is frequently confirmed radiographically. Case Report. A 79-year-old right-handed woman, with a past medical history of hypertension, hyperlipidemia, and prior transient ischemic attack (TIA), presented with acute onset global aphasia and right hemiparesis, in the absence of fever or prodrome. This was initially diagnosed as a proximal left middle cerebral artery (MCA) stroke. However, CT perfusion failed to show evidence of reduced blood volume, and CT angiogram did not show evidence of a proximal vessel occlusion. Furthermore, MRI brain did not demonstrate any areas of restricted diffusion. EEG demonstrated left temporal periodic lateralized epileptiform discharges (PLEDs). The patient was empirically loaded with a bolus valproic acid and started on acyclovir, both intravenously. CSF examination demonstrated a pleocytosis and PCR confirmed the diagnosis of herpes simplex viral encephalitis (HSVE). Conclusions. HSVE classically presents in a nonspecific fashion with fever, headache, and altered mental status. However, acute focal neurological signs, mimicking stroke, are possible. A high degree of suspicion is required to institute appropriate therapy and decrease morbidity and mortality associated with HSVE.

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Diagnostic delay in a case of herpes simplex encephalitis

Cited by 6 publications

References 13 publications

Herpes Simplex Virus Encephalitis: Atypical Presentation as a Right Middle Cerebral Artery Stroke

Herpes Simplex Virus Encephalitis: Atypical Presentation as a Right Middle Cerebral Artery Stroke

Pitfalls associated with the diagnosis of herpes simplex encephalitis

Herpes Simplex Viral Encephalitis Masquerading as a Classic Left MCA Stroke

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