Khan Adeel, Khan Malik Hasnat Ul Hassan, Khan Salman Ullah, Hayat Khizar, Khan Ayesha, Arsalan Muhammad, Mushtaq Muhammad Hamza, Sarfaraz Haider, Abbas Muhammad
Internal Medicine, Khyber Medical College, Peshawar, PAK.
Internal Medicine, Medical Teaching Institute, Lady Reading Hospital, Peshawar, PAK.
Cureus. 2024 Sep 6;16(9):e68816. doi: 10.7759/cureus.68816. eCollection 2024 Sep.
Herpes encephalitis is caused by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). One of the infrequent complications of herpes encephalitis is cerebral venous thrombosis (CVT) because of the inflammation in the brain parenchyma. We report a unique and challenging case of a 14-year-old female patient presenting with confusion, headache, and fever. On examination, there was no neck rigidity and a negative Kernig's sign with no focal neurological deficits. Systemic examination was done to rule out other systems as a cause for her symptoms, and she was empirically treated as a case of encephalitis. An initial computed tomography (CT) scan of the brain without contrast was normal except for a subtle hypoattenuating area involving the right thalamus. Cerebrospinal fluid (CSF) analysis revealed viral infection while we awaited the results of CSF polymerase chain reaction (PCR) and culture analysis for specific microorganisms. Her Glasgow Coma Scale (GCS) deteriorated following an episode of generalized tonic-clonic seizure, and she was subsequently catheterized and an enteral feeding tube (nasogastric tube) was passed. CSF PCR detected HSV-1. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain with contrast revealed encephalitis with superior sagittal sinus, transverse sinus, straight sinus, and vein of Galen thrombosis yielding a diagnosis of HSV encephalitis with concurrent cerebral venous thrombosis. Hence, this required a very specialized and cautious approach to her treatment. She was started on intravenous acyclovir and subcutaneous enoxaparin, and she recovered over the next few days. She did, however, develop acyclovir-induced renal toxicity in the absence of another offending agent, and the dose of the acyclovir was adjusted accordingly. A diagnosis of CVT, although rarely described, should be systematically suspected in patients with HSV encephalitis presenting with sudden deterioration or unexpected neurological findings in the early phase of treatment or inadequate response to treatment for better management and outcomes.
疱疹性脑炎由1型单纯疱疹病毒（HSV-1）或2型单纯疱疹病毒（HSV-2）引起。疱疹性脑炎的罕见并发症之一是脑实质炎症导致的脑静脉血栓形成（CVT）。我们报告了一例独特且具有挑战性的病例，一名14岁女性患者，表现为意识模糊、头痛和发热。检查时，无颈项强直，克氏征阴性，无局灶性神经功能缺损。进行了全身检查以排除其他系统导致其症状的原因，并经验性地将其作为脑炎病例进行治疗。最初的脑部计算机断层扫描（CT）平扫除了右侧丘脑有一个细微的低密度区外，其余均正常。脑脊液（CSF）分析显示病毒感染，同时我们等待CSF聚合酶链反应（PCR）和针对特定微生物的培养分析结果。在一次全身性强直阵挛发作后，她的格拉斯哥昏迷量表（GCS）评分恶化，随后进行了导尿并插入了肠内喂养管（鼻胃管）。CSF PCR检测到HSV-1。脑部增强磁共振成像（MRI）和磁共振静脉血管造影（MRV）显示为脑炎伴上矢状窦、横窦、直窦和大脑大静脉血栓形成，从而诊断为HSV脑炎并发脑静脉血栓形成。因此，这需要对其治疗采取非常专业和谨慎的方法。她开始接受静脉注射阿昔洛韦和皮下注射依诺肝素治疗，在接下来的几天里康复。然而，在没有其他致病因素的情况下，她出现了阿昔洛韦诱导的肾毒性，因此相应调整了阿昔洛韦的剂量。对于患有HSV脑炎且在治疗早期出现突然恶化或意外神经学表现或对治疗反应不佳的患者，为了更好地管理和改善预后，应系统地怀疑CVT的诊断，尽管相关描述很少。
