A 51-year-old diabetic woman was admitted to hospital with fever and acute confusion. In the emergency department, no signs of meningeal irritation and focal neurological signs were detected. A CCT was unremarkable [] and lumbar puncture showed 1 cell/μL (normal < 4) and slightly elevated protein 646 mg/dl (normal < 450) with normal glucose. As blood glucose was high (351 mg/dl), an infection triggered diabetic disorder was suspected. Therefore the patient was treated by the internist. The following day the patient suffered from aphasia. Since aphasia persisted, a stroke of the left temporal lobe was assumed next. However, as fever continued and confusional symptoms predominated, a second lumbar puncture was performed. The result, this time, showed elevated cell count (31 cells/μL, normal < 4) and elevated protein 1157 mg/dl (normal < 450). HSV was tested positive in the first and second CSF sample by PCR. Despite virostatic therapy with intravenous acyclovir (10 mg/kg every 8 h for 21 days), the patient's condition deteriorated, making mechanic ventilation and intensive care necessary. Furthermore neuroradiologically severe left-hemispheric encephalitic changes could be observed []. After a prolonged rehabilitation program, the patient is at home, but needs professional care.
A 76-year-old woman was transferred to our facility for acute right middle cerebral artery (MCA) stroke. She initially presented with headache, left sided weakness, intermittent fever, and generalized malaise. She also developed laceration on the back of head due to syncopal attack. Prior to presentation, she had fever, productive cough, and dyspnea and was treated with antibiotics for pneumonia. Her past medical history included hypertension, atrial fibrillation, congestive heart failure, and chronic obstructive lung disease.\nAt an outlying facility emergency room (ER), her physical exam was concerning for altered mental status, left-sided weakness, and mild respiratory distress. No meningeal signs were observed. Her laboratory findings included mild leukocytosis. All cultures remained negative. Head and chest imaging were unrevealing. A lumbar puncture (LP) could not be performed because of her elevated international normalized ratio (INR) due to regular warfarin use for atrial fibrillation. She was treated empirically with acyclovir, ceftriaxone, and vancomycin. Her mental status worsened. A repeat computed tomography (CT) scan demonstrated a stroke within the medial right temporal lobe. She was transferred immediately to our tertiary care for urgent magnetic resonance imaging (MRI) and a higher level of care.\nAt the time of presentation to our hospital, she was found to have an altered mental status with left-sided hemiparesis. She was febrile, tachypneic, and tachycardiac with elevated blood pressures. A repeat CT scan showed an acute right middle cerebral artery (MCA) infarct associated with significant gyral swelling, causing a left midline shift of 4 millimeters (mm) (Figure ). A brain magnetic resonance imaging (MRI) (Figure ) confirmed CT findings. Computed tomography angiography (CTA) did not show any acute intracranial arterial abnormality. Tissue plasminogen activator (TPA) was not administered as the patient was out of the thrombolytic window.\nOur working differentials included acute ischemic stroke and herpes encephalitis. Due to the patient's atypical presentation of altered mental status, headache, left-sided weakness, syncopal episode, and radiographic findings of stroke, an electroencephalogram (EEG) was performed, which showed a high epileptogenic potential in the right hemisphere with poor localization. Hypertonic saline was started to reduce brain edema, along with IV acyclovir 10 mg/kg thrice a day and levetiracetam. As the edema subsided and INR normalized, an LP was performed. Polymerase chain reaction analysis of CSF was positive for herpes simplex virus (HSV) type one, supporting the diagnosis of herpetic encephalitis.\nA video EEG to check therapeutic and prognostic response after treatment was done. On the fifth day, the patient showed significant clinical improvement.