Mohammad Abdullah, Mohammad Masroor, Syed Ahmad Asif.
Is it Herpes Encephalitis?.
J Coll Physicians Surg Pak Jan ;9(3):154-7.

A case of Herpes Encephalitis, is reported here who had a very peculiar MRI. He presented with a history of repeated fits and high grade fever and was in deep coma. He responded remarkably to early IV Acyclovir. His MRI showed diffuse involvement of right cerebral cortex and contralateral cerebellum. Such a wide spread involvement of brain on MRI has not been reported in a case of Herpes encephalitis.

CASE REPORT: A 21 years old male with a past history of delayed mile stones and generalized tonic clonic seizure disorder, never been on proper anti-epileptics, was admitted through emergency with 2 days history of high grade fever, and one day history of repeated generalised fits and unconsciousness. Fever was sudden in onset, high grade, intermittent, associated with vomiting, and episodic generalized headach. On the day of admission, he woke up with a scream. At the time of admission, encephalitis (most likely herpes encephalitis), meningoencephalitis, and cerebral malaria were considered to be the likely differential diagnoses. After sending the blood and CSF samples, he was empirically put on Inj. Acyclovir, Inj Cefotaxime, and Inj. Artem. Investigations were pointing towards a viral picture, so acyclovir was continued, and rests of other medications were stopped. Temperature settled down to normal in 24 hours and patient opened eyes on 3rd day of admission. CT scan brain done on the 4th day of admission showed a large hypodense area in right cerebral hemisphere with loss, of sulci and compression of ipsilateral lateral ventricle indicating diffuse edema. IV contrast injection resulted in enhancement of right insular and temporal regions. Considering large, diffuse edema of cerebrum, IV dexamethasone was added. On 5th day of admission repeat CNS examination revealed GCS 12-13/15. Patient had mild difficulty in following commands. Acyclovir was continued for 12 days and so was steroid. Patient kept on improving progressively. To follow up the case, MRI brain was performed on eleventh day of admission, which showed diffuse edema of right cerebral hemisphere. Signal from the involved area was almost isointense on T,WI and hyperintense on TWI Similar signal was also present in left (contralateral) cerebellar hemisphere. Signals from both the temporal lobes were almost similar. To rule out any possible aetiology in cardio vascular system, resulting in a vascular event causing such an MRI appearance, echocardiography, collagen profile, and 4 vessel intracranial angiography were also performed. All of these investigations turned out to be normal.

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