Case report:

A 37-year-old male presented to our hospital with persistent severe headache and fever. He was apparently well 8 days back when he had malaise and moderate headache. Following this, the same day he had fever of recorded temp of 104F with chills and rigor associated with generalized myalgia but reported no vomiting, photophobia or loss of consciousness. The next day he had multiple episodes of vomiting followed by an episode of loss of consciousness associated with tonic spasm of body and followed by clonic jerky movements of limbs for about one minute. It was associated with frothing from the mouth, lateral tongue bite and deviation of angle of mouth to the left side. There was no bowel bladder incontinence. It was followed by period of post ictal confusion for about half an hour where he couldn’t speak coherently but was able to move all four limbs. He was swiftly taken to nearby hospital and managed as seizure disorder. During the six days stay at the hospital he did not have another episode of loss of consciousness but fever and headache persisted which were still moderate in intensity. Likewise, after the first three days of hospital stay he complained of increased somnolence and was disorientation to time and place. He developed irrelevant talking and mutism at other times. Thus, dissatisfied with the level of care and deteriorating status of patient, the family members brought him to our hospital after being discharged on patient request. On presentation, he had a fever of 102F. On CNS examination his naming, short term, and long term memory were impaired. His sensory and motor examination were intact. There were no cerebellar or meningeal signs. Planters were bilateral downgoing. His chest and cardiovascular examination were within normal limits. Thus with these background clinical features a provisional diagnosis of viral encephalitis was made and acyclovir started.
Investigations were sent, including blood investigation, cerebrospinal fluid (CSF) analysis. Here total white blood cells (WBC)counts were raised to about 19680 cells/ cu mm3 and blood sodium was 127mEq/L rest were within normal limits. On CSF examination, his blood count was raised to 200 cells/cu mm with monomorphs of 40% and polymorphs of 60%, sugar level was normal (60), and protein was raised (159); RBCs were not mentioned. Microbiological exam of CSF showed no growth on culture and no bacterial cells on gram stain. MRI brain showed features suggestive of herpes encephalitis involving right temporal lobe and cingulated gyrus without any signs of hemorrhage as depicted in figure 1. These findings were supportive of our provisional diagnosis of viral encephalitis. Thus, CSF Polymerase chain reaction (PCR) was sent which came positive for HSV 1 DNA. Thus a final diagnosis of HSV 1 encephalitis was made.
However, on day six he began to develop severe headache and begun to be disoriented to time place and person. Consequently, a head Computed Tomography (CT) scan of head showed hematoma on right temporal lobe, as seen on the figure 2. A coagulation profile was done at that time showed no abnormality. Therefore, he was shifted to medical ICU for close monitoring of his hemodynamic and neurological status. The headache persisted for three more days then gradually subsided. To address the raised ICP head elevation was done, mannitol and hypertonic saline were used but steroids were not. No surgical interventions were needed. He was well oriented to time place and person by the end of sixth day of ICU stay. His naming, short term and long term memory were still impaired otherwise his neurological exam was the same. Following eight days of ICU stay he was shifted to general ward. On discharge, his naming, short term and long term memory function had not still recovered. Motor and sensory examinations were intact throughout. He had completed 21 days of acyclovir therapy. He was discharged after 27 days of hospital stay on levateracetam for seizure prophylaxis and was asked to come for follow up in 15 days. His assessment 15 days later, he still had problems with naming, short term and long term memories but was gradually improving. Rest of the neurological examinations were normal.