Pitfalls in the diagnosis of herpes simplex virus-1 encephalitis: case report
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LETTER TO THE EDITOR
Pitfalls in the diagnosis of herpes simplex virus-1 encephalitis: case report Yanping Wei 1
&
Hongzhi Guan 1
Received: 3 June 2020 / Accepted: 24 September 2020 # Fondazione Società Italiana di Neurologia 2020
Dear Editor, Herpes simplex virus-1 (HSV-1) is one of the most common infectious causes of sporadic encephalitis, and HSV-1 encephalitis (HSVE), and, if left untreated, can lead to poor outcomes or even death [1]. The incidence of HSVE worldwide is estimated to be between 2 and 4 cases/1,000,000 people, with an equal incidence in males and females; one-third of HSVE patients are younger than 20 years and one-half of patients are older than 50 years [1, 2]. It is difficult to distinguish HSVE from other types of encephalitis or encephalopathy because the most prevalent symptoms are fever, seizures, acute mental dysfunction, and headaches, all of which are nonspecific for HSVE [1]. We describe a patient with HSVE who was first suspected of having ischaemic stroke, anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, or mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS). This report emphasizes the challenges in the diagnosis of HSVE.
Case report A 66-year-old man presented with a 1-month history of headache, homonymous hemianopsia, aphasia, and psychiatric and cognitive symptoms and a 23-day history of seizures. One month before presentation, the patient complained of persistent headache, homonymous hemianopsia, aphasia, cognitive decline including disorientation and amnesia, and abnormal mental behavior including hallucinations, raving, and soliloquizing. The patient had a decreased ability of performing * Yanping Wei [email protected] 1
Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1, Dongcheng District, Beijing 100730, People’s Republic of China
housework and social activities. No fever, nausea, or vomiting were reported. Neurological examinations showed mental and cognitive disturbances, aphasia, and hemianopsia. Magnetic resonance imaging (MRI) of the brain demonstrated left frontal, temporal, and occipital lesions and abnormalities of the periventricular white matter, with hyperintense signals on T2-weighted imaging (T2WI) and hypointense signals on T1-weighted imaging (T1WI); among the lesions, a portion of the temporal lesions and left occipital lesions showed enhancement with gadolinium contrast and diffusion restriction on DWI. Magnetic resonance angiography (MRA) of the patient’s head showed slight narrowing of the right internal carotid artery. Considering the possibility of cerebral infarction, aspirin was given; however, the patient’s condition worsened (Fig. 1). A week later, epileptic seizures occurred and lasted several minutes each time. Surface electroencephalography (EEG) showed asymmetric, diffuse, slow-wave background activity over the left occipital lobe. The CSF was unremarkable except for slightly elevated protein levels of 52 m
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