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.
An 84-year-old woman was found on the floor with altered mental status and myoclonic jerks. Some days earlier, levofloxacin was prescribed by her physician due to cystitis. On admission, the patient was somnolent and disorientated, but without meningeal irritation. On both arms, myoclonic jerks could be observed. The working diagnosis in the emergency room was quinolone associated delirium. In order to exclude other etiologies, a CCT was performed, revealing a hypodense lesion in the right temporal lobe []. The following CSF analysis showed elevated lymphocytic cell count (36/μL; normal < 4) and protein (961 mg/dl (normal < 450)); lactate and glucose were normal []. A therapy with acyclovir (10 mg/kg every 8 h for 14 days) was initiated. PCR assay for HSV-1 was found to be positive. Gradually the patient recovered and took part in a rehabilitation program. A year later, the patient was admitted due to a symptomatic seizure. At this time, she still showed marked neurocognitive impairment, needing moderate home care.