The Journal of the Arkansas Medical Society Issue 2 Vol 115 | Page 14

SCIENTIFIC ARTICLE
An Unusual Stroke-Like Presentation
of HSV Encephalitis
1
Harsh V Gupta, MD 1 ; Samira Malhotra, MD 1 ; Amit Batra, MD, DM 1
Department of Neurology, Max Super Specialty Hospital, New Delhi, India.
Keywords:
encephalitis, stroke-like,
HSV, frontal lobe.
Abstract
H
SV (Herpes Simplex Virus) en-
cephalitis is a potentially life-
threatening illness that can af-
fect neonates as well as adults. 1 Despite
improvement in diagnostic techniques such as
magnetic resonance imaging (MRI) and cerebro-
spinal fluid (CSF) examination, challenges and
pitfalls remain in the diagnosis of this condition. 1
We are reporting a case of HSV encephalitis that
presented like a stroke with atypical MRI and
CSF findings. The possibility of HSV encephali-
tis in a patient with fever and focal neurological
deficit should always be kept in mind because
a full-blown picture such as seizures, abnormal
behavior, confusion, disorientation, etc., may not
be seen in every patient. 2
Case Report
A 69-year-old woman, otherwise healthy,
presented to the emergency department with
a sudden onset of headache, numbness, and
weakness in the left upper extremity. Her pre-
sentation was suggestive of an acute ischemic
stroke, but intravenous thrombolysis was not
considered as she arrived outside of the window
Initially, HSV encephalitis affects
one hemisphere and involves
the contralateral side once it has
extended in the initially involved
hemisphere. 4
Figure 1. Demonstrates hyperintensity on DWI sequence (A and B) in the right parafalcine region.
period. Neurologic examination revealed weak-
ness and hyperreflexia in left upper extremity.
MRI of the brain (stroke protocol) demonstrated
hyperintensity on diffusion-weighted imaging
(DWI) in the right frontal lobe corresponding with
the area of weakness (Figure 1). On hospital day
two, she developed a fever followed by urinary
incontinence. Urinalysis revealed leukocyturia
(50 white blood cells) and dipstick was positive
for leukocyte esterase. Intravenous ceftriaxone
was initiated empirically to treat urinary tract
infection. On hospital day three, she had a gen-
eralized tonic-clonic seizure followed by recur-
rent focal seizures involving the right side of face
and arm. Over the next few hours, her mental
status worsened and she was barely responsive
to stimuli. Her EEG showed bilateral independent
periodic lateralized epileptiform discharges (BI-
PLEDs). At this point, it was decided to repeat
brain imaging and perform a lumbar puncture. litis. Brain MRI showed the new development
of bilateral fluid attenuated inversion recovery
(FLAIR) hyperintensities involving the parafal-
cine frontal, temporal, anterior cingulate, and
insular region (Figure 2). Complete blood count,
lipid profile, hemoglobin A1c, blood culture, urine
culture, and echocardiogram were either normal
or negative. Autoantibodies in the serum against
N-methyl-D-aspartate (NMDA) receptor, alpha-
amino-3-hydroxy-5-methyl-4 isoxazolepropi-
onic acid (AMPA) receptor, gamma-aminobutyric
acid (GABAb) receptor,