Department of Neurology, Klinikum der Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, 81377, Munich, Germany.
Department of Neuroradiology, Klinikum der Ludwig-Maximilians-University (LMU) Munich, Marchioninistr. 15, 81377, Munich, Germany.
Infection. 2019 Apr;47(2):267-273. doi: 10.1007/s15010-018-1257-7. Epub 2018 Dec 1.
Herpes simplex virus (HSV) encephalitis continues to be the most common form of sporadic lethal encephalitis worldwide. The wide spectrum of clinical presentations and laboratory findings often poses a diagnostic challenge for physicians which might delay administration of life-saving therapy with acyclovir. Atypical presentations of HSV encephalitis have become increasingly prevalent with better diagnostic techniques and have not been well studied.
We retrospectively evaluated all consecutive PCR-proven HSV encephalitis cases treated at the Hospital of the Ludwig-Maximilians-University in Munich, Germany from January 1, 2013 to February 28, 2018.
We included 18 patients with PCR-proven HSV encephalitis. The most common clinical features were altered mental status (77.8%), focal neurologic deficits (72.2%) and fever (72.2%). Remarkably, four of these patients (22.2%) had a normocellular cerebrospinal fluid (CSF) on admission. Electroencephalography and magnetic resonance imaging abnormalities were highly sensitive for HSV encephalitis independent of CSF cell count. Striking atypical findings on MRI were extensive global brain swelling and severe brainstem involvement in single patients. Of note, initial CT scans were normal in 11 out of 16 patients (68.8%). All patients were treated with acyclovir. Three patients still developed a clinical deterioration under therapy with acyclovir with one patient requiring decompressive craniotomy due to bilateral space-occupying temporal lobe hemorrhage. 94.4% of the patients survived but only 38.9% were discharged with a good clinical outcome (Glasgow Outcome Score = 5).
Atypical presentations of HSV encephalitis seem to be more common than previously thought and physicians should apply a high level of clinical suspicion and a low threshold to initiate life-saving acyclovir therapy in suspected cases.
单纯疱疹病毒（HSV）脑炎仍然是世界范围内最常见的散发性致死性脑炎。广泛的临床表现和实验室发现常常给医生带来诊断挑战，这可能会延迟使用阿昔洛韦进行救生治疗。随着诊断技术的提高，HSV 脑炎的不典型表现变得越来越普遍，但尚未得到很好的研究。
我们回顾性评估了 2013 年 1 月 1 日至 2018 年 2 月 28 日在德国慕尼黑路德维希-马克西米利安大学医院治疗的经 PCR 证实的单纯疱疹病毒脑炎的所有连续病例。
我们纳入了 18 例经 PCR 证实的单纯疱疹病毒脑炎患者。最常见的临床特征是精神状态改变（77.8%）、局灶性神经功能缺损（72.2%）和发热（72.2%）。值得注意的是，这些患者中有 4 例（22.2%）入院时脑脊液细胞数正常。脑电图和磁共振成像异常对 HSV 脑炎具有高度敏感性，与脑脊液细胞计数无关。在单个患者中，磁共振成像上出现广泛的全脑肿胀和严重的脑干受累，这些都是显著的不典型表现。值得注意的是，16 例患者中有 11 例（68.8%）的初始 CT 扫描正常。所有患者均接受阿昔洛韦治疗。在接受阿昔洛韦治疗的 3 例患者中，病情仍出现恶化，其中 1 例因双侧颞叶占位性出血需要行减压性颅骨切开术。94.4%的患者存活，但只有 38.9%的患者出院时临床预后良好（格拉斯哥预后评分=5）。
HSV 脑炎的不典型表现似乎比以前认为的更为常见，医生在疑似病例中应高度怀疑，并降低开始救生性阿昔洛韦治疗的门槛。
