Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 4, 2011, pp. 594-596

Neurology India, Vol. 59, No. 4, July-August, 2011, pp. 594-596

Case Report

Herpes simplex virus encephalitis complicated by intracerebral hematoma

Satoru Takeuchi¹, Yoshio Takasato²

¹ Department of Neurosurgery, National Defense Medical College, Saitama, Japan
² National Hospital Organization Disaster Medical Center, Tokyo, Japan
Correspondence Address: Satoru Takeuchi
Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan, s.takeuchi@room.ocn.ne.jp

Date of Submission: 18-Feb-2010
Date of Decision: 28-Dec-2010
Date of Acceptance: 17-Jan-2011

Code Number: ni11177

PMID: 21891940

DOI: 10.4103/0028-3886.84344

Abstract

Keywords: Encephalitis, herpes simplex virus, intracerebral hematoma

Introduction

Herpes simplex virus (HSV) encephalitis is the most common cause of sporadic encephalitis, with a mortality of 70% if untreated. Treatment with acyclovir is associated with reduced mortality. Petechial cortical hemorrhages are common in HSV encephalitis, whereas frank hematoma is extremely rare; only 10 cases have been reported in the literature. ^{[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]} We report another case of HSV encephalitis complicated by intracerebral hematoma and review the literature.

Case Report

A 54-year-old man was admitted with a 2-day history of fever, difficulty in walking, and mental confusion. He had a general seizure at admission. He was being treated for hypertension. His vitals were: temperature, 39.7°C; blood pressure, 170/143 mmHg; pulse rate, 179 beats/min; and respiratory rate, 30 breaths/min. On neurologic examination, he was in coma with left hemiparesis. Laboratory workup revealed the following: C-reactive protein, 0.1 mg/L; white cell count (WBC), 13,700/mm ³ , and cerebrospinal fluid (CSF) analysis on day 2, WBC count of 86 cells/mL (69% mononuclear cells); protein, 56.3 mg/dL; and glucose, 90 mg/dL. CSF samples were positive for HSV-DNA by polymerase chain reaction. Brain computed tomography (CT) on day 2 showed a slightly low-density area in the medial side of the right temporal lobe, with an obscured sulcus [Figure - 1]a. He was diagnosed as a case of HSV encephalitis and was started on acyclovir (1500 mg/day, 2 weeks). Brain fluid-attenuated inversion recovery magnetic resonance imaging (MRI) on day 7 showed a focal area of increased signal in the right temporal lobe [Figure - 1]b. His neurologic condition recovered gradually. However, brain CT scan on day 10 showed a hematoma in the right medial temporal lobe, without mass effect [Figure - 1]c. He was managed conservatively as his condition was stable. The hematoma showed no further progression and gradually resolution. The patient was transferred to another hospital on day 15 for rehabilitation for mild left hemiparesis and short-term memory disturbance.

Discussion

HSV encephalitis complicated by intracerebral hematoma is extremely rare and the characteristics of the 11 cases, including the present case, are summarized in [Table - 1]. ^{[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]} Only two patients including our patient had higher blood pressure reading at admission. The hematoma location was in the medial temporal lobe in six patients and exhibited a gyral pattern, which differed from spontaneous intracerebral hematoma. Hemorrhagic complication occurred during acyclovir treatment (5-15 days) in six patients, suggesting that initiation of treatment may not affect this complication. Hemorrhagic complication was associated with poor outcome, only three patients had good recovery and six had moderate to disability.

The mechanism of hemorrhagic complication in HSV encephalitis is unclear. The possible mechanisms proposed by Fukushima et al. ^[10] include small vessel rupture due to vasculitis and transient hypertension caused by increased intracranial pressure. Gyral pattern of the hemorrhage may suggest that the hemorrhagic complication in HSV encephalitis may be due to associated vasculitis. Hematoma formation in the cases described here tended to occur at a relatively late stage (mean interval from onset to hematoma formation, approximately 12 days), which supports this hypothesis.

References

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