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[Herpetic simplex encephalitis followed by myelopathy]
K Nakamura1, T Terasaki, T Tsuchiya
1Department of Medicine, National Cardiovascular Center, Osaka, Japan.
Abstract:
A 48-year-old male was admitted to our hospital because of fever, headache and vomiting. At admission, the level of consciousness was depressed (drowsy) with slight confusion. Extremely miotic pupils, nuchal stiffness, ataxia and myoclonic movements of both upper limbs were observed. The eye movements were almost normal and there was no definite limb weakness or sensory impairment. A few days after admission, his level of consciousness further decreased, and opsoclonus, ataxic breathing and intestinal paralysis appeared. The body temperature fluctuated remarkably ranging from 33.0 degrees C to 39.0 degrees C. The cerebrospinal fluid (CSF) examination revealed lymphocytic dominant pleocytosis, increase of protein and decrease of glucose. Enzyme-linked immunosorbent assay (ELISA) showed increased antibody (IgG) to herpes simplex virus (HSV) in both serum and CSF. The antibody in CSF further elevated at the later examination. Magnetic resonance imaging (MRI) demonstrated high signal intensity areas mainly in the cerebellum and sporadically in the supratentorial subcortical white matter on T2-weighted images. Administration of Gadolinium-DTPA also revealed an additional lesion in the pons. From these findings, he was diagnosed as herpetic encephalitis involving the brainstem and the cerebellum, and acyclovir was administered. Although his initial symptoms and signs started to recover three weeks after admission, he newly developed complete flaccid paraplegia, dysuria and sensory disturbance with the spinal cord level of the 4th thoracic segment. The oligoclonal IgG bands were detected in the cerebrospinal fluid of the convalescent stage.(ABSTRACT TRUNCATED AT 250 WORDS)
Insights
Herpetic encephalitis, caused by herpes simplex virus (HSV), can affect the brainstem and cerebellum. This case highlights potential spinal cord involvement and the importance of timely diagnosis and treatment for neurological recovery.
Area of Science:
- Neurology
- Infectious Diseases
- Neuroimmunology
Background:
- Herpetic encephalitis is a severe neurological condition often caused by herpes simplex virus (HSV).
- Early diagnosis and treatment are crucial for improving patient outcomes.
- Understanding the full spectrum of neurological involvement is essential for comprehensive patient care.
Observation:
- A 48-year-old male presented with fever, headache, vomiting, altered consciousness, and neurological deficits including ataxia and myoclonus.
- Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, elevated protein, and decreased glucose, with elevated herpes simplex virus (HSV) IgG antibodies.
- Magnetic resonance imaging (MRI) showed lesions in the cerebellum, supratentorial white matter, and brainstem, consistent with herpetic encephalitis.
Findings:
- The patient was diagnosed with herpetic encephalitis involving the brainstem and cerebellum, treated with acyclovir.
- Despite initial recovery, the patient developed paraplegia and sensory disturbances, indicating spinal cord involvement.
- Detection of oligoclonal IgG bands in CSF during the convalescent stage suggests a potential post-infectious or autoimmune process.
Implications:
- This case underscores the potential for herpetic encephalitis to cause widespread central nervous system (CNS) and spinal cord inflammation.
- The presence of oligoclonal bands may indicate an immune-mediated component contributing to neurological damage.
- Further research is needed to elucidate the mechanisms of spinal cord involvement in herpetic encephalitis and optimize treatment strategies.