Shoaib Maria, Kraus Jacqueline J, Khan Muhammad T
Department of Medicine, Dow Medical College Pakistan.
Attending Physician, Charleston Area Medical Center / West Virginia University.
Cureus. 2018 Jan 15;10(1):e2067. doi: 10.7759/cureus.2067.
Herpes simplex virus encephalitis (HSVE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis. We report a case of HSVE presenting as a stroke mimic in a 76-year-old female with a history of atrial fibrillation on warfarin. She was admitted to our medical intensive care unit with intermittent fever, lethargy, and new onset left-sided hemiparesis. A computed tomography (CT) of the head showed a right middle cerebral artery (MCA) acute ischemic stroke with midline shift and a dense right MCA sign. Brain magnetic resonance imaging (MRI) showed evidence of acute stroke with consideration of herpes encephalitis. CSF analysis was positive for herpes simplex virus (HSV) type one. She recovered with high-dose intravenous acyclovir therapy. Our patient was a diagnostic dilemma, initially being diagnosed with an acute ischemic stroke and yet found to have HSVE, which mimicked an acute ischemic stroke. Delay in treatment may result in devastating clinical outcomes that may include severe cognitive, focal neurological deficits, persistent seizures, and even death. This case highlights the importance of a multidisciplinary approach and the need for increased awareness of an atypical presentation of HSVE among emergency physicians, neurologist, intensivists, and radiologists.
单纯疱疹病毒性脑炎（HSVE）是一种与高死亡率和高发病率相关的医疗急症。通过病史、临床检查、神经影像学研究、支持性脑电图（EEG）结果和脑脊液（CSF）分析来确诊。我们报告一例76岁有华法林治疗房颤病史的女性患者，其HSVE表现类似中风。她因间歇性发热、嗜睡和新发左侧偏瘫入住我们的医学重症监护病房。头部计算机断层扫描（CT）显示右侧大脑中动脉（MCA）急性缺血性中风伴中线移位和右侧MCA致密征。脑磁共振成像（MRI）显示有急性中风迹象，考虑为疱疹性脑炎。脑脊液分析显示单纯疱疹病毒（HSV）1型阳性。她接受大剂量静脉注射阿昔洛韦治疗后康复。我们的患者诊断存在困境，最初被诊断为急性缺血性中风，但后来发现患有HSVE，后者表现类似急性缺血性中风。治疗延迟可能导致严重的临床后果，包括严重认知障碍、局灶性神经功能缺损、持续性癫痫发作甚至死亡。该病例凸显了多学科方法的重要性，以及急诊医生、神经科医生、重症监护医生和放射科医生提高对HSVE非典型表现认识的必要性。
