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Atypical Brainstem Encephalitis Caused by Herpes Simplex Virus 2
Kon Chu, MD;
Dong-Wha Kang, MD, PhD;
Jung-Ju Lee, MD;
Byung-Woo Yoon, MD, PhD
Arch Neurol. 2002;59:460-463.
Background Herpes simplex encephalitis is one of the most common and serious sporadic
encephalitides of immunocompetent adults. Herpes simplex virus 2 (HSV-2) infections
of the central nervous system usually manifest as subacute encephalitis, recurrent
meningitis, myelitis, and forms resembling psychiatric syndromes.
Objectives To report and discuss magnetic resonance imaging (MRI) findings and
clinical features in atypical brainstem encephalitis and facial palsy associated
with HSV-2.
Setting Neurology department of a tertiary referral center.
Patient A 37-year-old woman was admitted to the hospital with fever, diplopia,
left hemiparesis, sensory change in the face and limbs, personality changes,
frontal dysexecutive syndrome, and a stiff neck. Brain MRI showed multifocal
high-signal intensities in the pons, midbrain, and frontal lobe white matter
on T2-weighted and fluid-attenuated inversion recovery images. Cerebrospinal
fluid (CSF) polymerase chain reaction (PCR) amplification analysis was positive
for HSV-2. Acyclovir therapy was started, and the encephalitic symptoms disappeared
with a negative conversion of HSV-2 PCR in the CSF. However, after the discontinuation
of acyclovir therapy, peripheral facial palsy occurred on the left side. A
possible relapse or delayed manifestation of the HSV-2 infection was suspected,
and the acyclovir therapy was restarted. A complete remission was achieved
3 days after the treatment. She was discharged without any neurologic sequelae.
Conclusions We describe a patient who developed atypical encephalitis due to HSV-2
and peripheral facial palsy, which could also be related to the HSV-2. This
case suggests that HSV-2 should be considered among the possible causes of
atypical or brainstem encephalitis and that the PCR amplification method of
the CSF can help reveal the possible cause of HSV-2.
From the Department of Neurology and Clinical Research Institute (Drs
Chu, Kang, and Lee), and Neuroscience Research Institute (Dr Yoon), Seoul
National University Hospital, Neuroscience Research Institute of SNUMRC (Drs
Chu, Kang, Lee, and Yoon), Seoul, Korea.
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