Hazim Barohi, Mohammad Wasay, Nadir Ali Syed, Shahid Baig, Tariq Moattar, Arif Sarwari.
Atypical Presentations of Herpes Simplex Encephalitis Diagnosed by Polymerase Chain Reaction (PCR).
Infect Dis J Jan ;10(1):2-4.

We reviewed the clinical characteristics, CSF analysis, EEG, and CT/ MRI of eight patients with PCR positive HSE and atypical presenting features. Patient I : A 15-year-old boy presented with sudden onset of bilateral parotid swelling, vomiting, weakness and drowsiness. The neurological examination was unremarkable, except for lethargy and global aphasia. His laboratory tests showed pancytopenia, elevated d-dimer consistent with DIC and hypocalcaemia. CSF showed glucose 34 mg/dL, protein 114 mg/dL, 60 cells, which were predominantly fragmented. EEG was normal. MRI showed abnormal signals involving temporal lobes on flair images. He was treated with Acyclovir for 14 days, and recovered completely. Patient 2: A 17 year old male presented with parotid gland swelling and generalized seizures. Neurological examination was unremarkable except for lethargy. CT scan was normal. CSF showed glucose 91 mg/dL, proteins 62.5 mg/dL, 56 WBCs/cmm, with 10% neutrophils and 90 % lymphocytes and 450 RBCs/cmm. Due to rapid improvement he was not treated with acyclovir. Neurological examination at discharge was normal. Patient 3: A 22-year-old man presented with headache, neck pain, vomiting, fever and altered mental status. His neurological examination was only remarkable for blurring of optic disc margins and positive Babinski sign. MRI was normal. CSF showed glucose 64 mg /dL, proteins 112 mg/dL, 200 WBCs/cmm, with 80% neutrophils and 500 RBCs/cmm. EEG showed diffuse slowing more prominent over left hemisphere with right anterior temporal sharp waves. He was treated with acyclovir for 10 days and showed complete recovery. Patient 4: A 24-year-old male presented with fever, headache, vomiting and unresponsiveness. Neurological examination was unremarkable except altered mental status. MRI showed increased T2 signals in frontal, parietal and parasagital region. Right hemispheric slowing was noted on EEG. CSF showed glucose 53 mg/dL, proteins 68 mg/dL, 140 WBCs/cmm, with 94 lymphocytes and 2,570RBCs/cmm. He received acyclovir for LO days, but was discharged in a vegetative state from hospital. However on one year follow up, he was ambulatory, with only moderate. Patient 5: A 29-year-old woman presented with fever, confusion and seizures. Examination revealed a young confused female with no focal neurological deficit. CSF showed glucose 104 mg/dL, proteins 46 mg/dI., 10 WBCs/cmm, with 90% lymphocytes and 800 RBCs/cmm. CT scan showed hypodensity in the right cerebral peduncle. EEG showed diffuse slowing. She received acyclovir for 10 days and showed complete recovery.

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