An unlikely culprit: a case report of hsv-1 encephalitis leading to cerebrovascular complications and progression of the disease after treatment

SESSION TITLE: Critical Care Case Report Posters 71 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: HSV-1 accounts for majority of sporadic cases of encephalitis cases worldwide and carries up to 30% mortality despite antiviral treatment. We present a case of a 60 year old male with mantle cell lymphoma who was found to have HSV-1 encephalitis, complicated by the development of multiple strokes and progression of the disease. CASE PRESENTATION: Patient is a 60 year old male with a history of mantle cell lymphoma (CD5+, translocation 11,14), hypertension, and diabetes mellitus who presented for evaluation of vomiting, weakness and encephalopathy. On admission, his labs were significant for severe hyponatremia (116 MMOL/L) and Leukocytosis to 34.4 (K/cmm). Hyponatremia improved with administration of hypertonic saline but minimal improvement of encephalopathy was noted. Broad spectrum antimicrobial coverage was started due to concern of intracranial infection. Patient's next of kin had elected for code status to be DNR/DNI with limited invasive interventions. MRI of the brain revealed focal regions of diffusion signal abnormality at the insular cortex and hippocampus with lesser extent to right anterior temporal lobe and cortical surface of frontal lobes. VEEG showed diffuse slowing. Lumbar puncture showed 8 RBCs (cells/mm3), 22 WBC (cells/mm3), 70% Lymphocytes, protein (36 mg/dl), and glucose 181 (mg/dl) with concomitant serum glucose of 310 (mg/dl). Surprisingly, CSF culture was positive HSV-1. AB panel HSV 1 was positive, and IgM was 5972 (copies/ml). Patient completed a course of acyclovir leading to improvement in mentation but incomplete resolution of encephalitis. Hospital course was complicated by development of acute/subacute strokes in left central pons and left posterior temporal lobe and progression of the encephalitis noted on repeat MRI brain, as well as development of MDRO Pseudomonas pneumonia. DISCUSSION: HSV-1 accounts for most of the sporadic fatal encephalitis cases worldwide(1). In the majority of patients, CSF findings show lymphocytic pleocytosis, elevated protein, normal glucose with xanthochromia or erythrocytosis, however CSF may be normal in up to 5% of cases (1). HSV PCR in the CSF is the gold standard test for diagnosis, as it has > 95% sensitivity and specificity for the disease(1). MRI findings of the brain may include asymmetric T2-weighted sequences of hyperintensity in the insular cortex, mesiotemporal and orbitofrontal lobes(1). While, diffusion-weighted imaging (DWI) may show diffusion restriction of anterior temporal lobes and the insular cortex (1,2-3). Case reports have shown cerebrovascular complications associated with acute HSV encephalitis in some patients(5). Treatment of choice is acyclovir for a duration of up to 21 days(4), however, there are case reports of apparent relapse of HSV encephalitis after completion of antiviral therapy (6). HSV encephalitis is associated with mortality up to 30% despite appropriate medical therapy(1). CONCLUSIONS: Though up to 90% of the general population is seropositive for HSV-1(11), additional studies are needed for evaluation of risk factors for development of HSV-1 encephalitis, as well as factors contributing to rare cerebrovascular complications associated with the disease and its progression. Despite maximal therapy morbidity and mortality remains high, thus clinicians must be alert when encountering patients with encephalitis and provide appropriate therapy at onset of suspicion of the disease. REFERENCE #1: Kennedy PGE, Chaudhuri AHerpes simplex encephalitisJournal of Neurology, Neurosurgery & Psychiatry 2002;73:237-238 REFERENCE #2: Misra, U. K., J. Kalita, R. V. Phadke, V. Wadwekar, D. K. Boruah, A. Srivastava, P. K. Maurya, and A. Bhattacharyya. "Usefulness of Various MRI Sequences in the Diagnosis of Viral Encephalitis." Acta Tropica 116, no. 3 (December 2010): 206–11. REFERENCE #3: Sawlani, Vijay. "Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Evaluation of Herpes Simplex Encephalitis and Japanese Encephalitis." Journal of the Neurological Sciences 287, no. 1–2 (December 15, 2009): 221–26. 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