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.