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Herpes simplex virus encephalitis: problems in diagnosis
P D Cameron1, S J Wallace, J Munro
1Department of Child Health, University Hospital of Wales, Heath Park, Cardiff.
Insights
Herpes simplex encephalitis (HSE) in children often presents atypically, leading to delayed diagnosis and poor outcomes. Early consideration and empirical acyclovir treatment are crucial, even with normal CT scans and absent fever.
Area of Science:
- Pediatric Neurology
- Infectious Diseases
- Neurovirology
Background:
- Herpes simplex encephalitis (HSE) is a severe neurological condition in children.
- Prompt diagnosis and treatment are critical for improving patient outcomes.
Observation:
- This study presents six pediatric cases of HSE with varied clinical presentations.
- Delayed antiviral treatment (beyond six days) occurred in three cases, with initial misdiagnoses including epilepsy, meningitis, and febrile seizures.
- Apyrexia and normal cranial CT findings were noted in two cases each, highlighting diagnostic challenges.
Findings:
- Encephalitic changes on electroencephalograms (EEGs) were observed in five children.
- Diagnosis was confirmed through serological titers, brain biopsy, vesicle culture, and cerebrospinal fluid (CSF) analysis.
- All six children experienced poor outcomes, underscoring the severity of delayed treatment.
Implications:
- HSE should be suspected in children with focal seizures, irrespective of fever or normal CT scans.
- Routine practice should include collecting CSF for viral diagnostics in suspected cases.
- Empirical treatment with acyclovir is recommended prior to definitive virological confirmation to improve outcomes.
Abstract:
Six children aged 13 days to nine years with herpes simplex encephalitis (HSE) are presented. Institution of appropriate antiviral treatment was later than six days in three cases; original diagnosis in these cases were post-traumatic epilepsy, bacterial meningitis and febrile convulsion. Initially pyrexia was absent in two cases and cranial CT was normal in two cases. Encephalitic changes were observed on the EEGs of five children. Diagnosis was confirmed by paired serological titres, brain biopsy, vesicle culture and CSF titres. The outcome for all six children was poor. HSE should always be considered in children presenting with focal seizures, even when apyrexial and with normal CT findings. In such situations, saving CSF for antibody titres or antigen identification should be routine practice. Treatment with acyclovir is justified before precise virological diagnosis has been established.