Herpes simplex virus encephalitis in pregnancy - a case report and review of reported patients in the literature

Abstract

BackgroundHerpes simplex virus (HSV) encephalitis is the most common sporadic cause of encephalitis with significant morbidity and mortality that is drastically reduced by early antiviral treatment.Case presentationWe report a 37 year old woman, 33 weeks pregnant, who presented with seizures due to proven HSV-1 encephalitis, and who had had a previous episode of probable viral encephalitis aged 14 years. She was successfully treated with aciclovir on both occasions and, in the latter, went on to deliver a healthy infant. This case is compared with 17 cases of HSV encephalitis in pregnancy in the literature identifying a predominance in the late 2nd and 3rd trimesters, perhaps in part due to immunological changes in pregnancy. The clinical presentation is also compared with non-pregnant patients with HSV encephalitis in the largest prospective UK and European studies. We also present practical advice on management from recent national guidelines.ConclusionWhen pregnant women present with new seizures, headache, impaired consciousness or altered behaviour urgent investigation is required to identify common diagnoses, such as eclampsia, venous sinus thrombosis and metabolic disturbances. Nevertheless, viral encephalitis is a very treatable cause of this presentation with potentially serious complications if missed, and may be more common in latter stages of pregnancy. Encephalitis should not be discounted if the patient is afebrile, has a normal Glasgow coma score, or the cerebrospinal fluid white cell count is only slightly elevated, as these features are well recognised in viral encephalitis.

Neurologic infections during pregnancy

“…HSV is the leading cause of sporadic encephalitis, primarily due to type-1 HSV. Eighteen cases of HSV encephalitis in pregnant women have been reported in the literature ( Whitley and Gnann, 2002 ; Dodd et al, 2015 ). The majority of HSV-1 encephalitis in pregnant women were identified in the third trimester, to a lesser extent in the second trimester, and rarely in the first trimester.…”

“…The majority of HSV-1 encephalitis in pregnant women were identified in the third trimester, to a lesser extent in the second trimester, and rarely in the first trimester. This is speculated to be related to estrogen and progesterone rise during late second and third trimester in pregnancy, which modulates an immunologic shift ( Dodd et al, 2015 ).…”

“…HSV-1 encephalitis in a pregnant woman presents as it would in a nonpregnant woman with headaches, fever, altered mental status, and seizures. Eighty-nine percent of pregnant women in a case review had fever, 67% had headache, and 45% had seizures ( Dodd et al, 2015 ). Other etiologies for seizures in a pregnant woman should be investigated and treated, including hyperemesis gravidarum, which results in vomiting, electrolyte imbalances, and potentially secondary seizures, and eclampsia, a hypertensive disorder of pregnancy.…”

Herpetic Encephalitis during Pregnancy: Case Report

“…Lesions from primary infections typically resolve after an average of three weeks. 1,[3][4][5][6][7] If vaginal delivery occurs during an active infection, the risk of neonatal transmission increased and thus cesarean delivery is preferred in such cases. 4,[8][9][10][11] Neuronal damage evident in HSE is not well understood, but is thought to be due to the capability of HSV-1 to induce cell death, a property not characteristic of HSV-2.…”

“…HSE is a neurologic emergency, and even in treated cases, complications and sequlae, including cognitive deficits (as happen with our case) and recurrent seizures, are common. 1,5,6 Treatment for herpes infection has many aspects. An important aspect to consider is primary prevention.…”