A 48-year-old man with known symptomatic epilepsy reported diarrhea and fever for some days. This was followed by a series of focally beginning secondary generalized seizures. Thus the emergency physician administered 7.5 mg midazolam intravenously and admitted the patient to the neurological department. On admission, the patient was sedated and presented residual aphasia. A meningeal irritation was not noted. The neurological signs and symptoms were interpreted as postictal. There were no visible injuries, therefore a series of seizures due to afebrile infection was presumed. The patient was observed under intermediate care aspects. The next 2 days the patient's condition improved, he was afebrile and no focal neurological deficits were present. The medication with levetiracetam was augmented to a dosage of 1500 mg/daily. Electroencephalography showed slightly slowed focal activity on the left temporal side on the background of normal alpha wave activity. The day before the planned discharge from inpatient care, the patient suffered with sudden onset of a series of epileptic seizures progressing to a convulsive status with high fever of 40°C. Oral intubation and mechanical ventilation became necessary in order to treat status epilepticus. As anticonvulsive agents phenytoin, levetiracetam, midazolam, and propofol were applied, the Cranial computed tomography (CCT) scan at this time revealed hyodensities in the right temporal lobe and the right insular cortex []. The left sided hypodensity is related to a former head injury. The following cerebrospinal fluid (CSF) analysis showed elevated lymphocytic cell count (27/μL; normal < 4) with normal glucose but elevated protein (699 mg/dl (normal < 450)), indicating an inflammatory CSF syndrome. Polymerase chain reaction (PCR) assay for HSV-1 was tested positive. A treatment regimen was implemented with acyclovir (10 mg/kg body weight) three times daily for 21 days. After 4 days of ventilation the patient could be extubated and improved clinically successful. Cranial magnetic resonance imaging (MRI) on day 10 showed extended encephalitic changes in the right frontal and temporal lobe []. After a rehabilitation program, follow-ups took place as an outpatient. Yet due to neuropsychological impairments he cannot work in his profession as a carpenter anymore. Under the current antiepileptic therapy (levetiracetam 1500 mg daily), the patient is seizure-free.
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.