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.
A 40-year-old left-handed Caucasian female with chronic headaches, along with a 20-pack-year smoking history, presented to an outside facility with one week of diffuse, generalized headache, fever, nausea, emesis, and photophobia. Her physical exam was without any focal neurological deficit. Initial cranial imaging was negative for hemorrhage. A lumbar puncture was performed and cerebrospinal fluid (CSF) studies demonstrated 558 white blood cells/mm3 with 100% monocytes, protein 115 mg/dL, and glucose 55 mg/dL. Polymerase chain reaction (PCR) of the CSF was positive for HSV-2. Taken together, the lymphocytic pleocytosis with elevated protein, along with CSF-PCR-positive staining for HSV, established the diagnosis of HSV-2 encephalitis.\nAcyclovir was initiated, and one week later while still hospitalized, she developed an acute altered mental status and left-sided weakness with cranial imaging showing a large right temporal lobe hemorrhage with significant midline shift. She was transferred to our facility where a computed tomography angiography (CTA), performed on arrival and shown in Figure , was negative for any underlying vascular lesion. There was again the demonstration of a large right temporal lobe intracerebral hemorrhage that was displacing the right middle cerebral artery superiorly as well as midline shift. Informed patient consent was waived due to her condition upon admission.\nShe was taken to the operating room for a decompressive unilateral (right) hemicraniectomy and temporal lobectomy. We had the operating room prepared for a possible vascular lesion despite the initial negative study. Figure -C demonstrates intraoperative images. A 15 x 12 cm (AP x lateral) craniectomy was measured out and performed, ensuring to stay within 2 cm off of the midline to avoid superior sagittal sinus bleeding []. The dura was opened in a cruciate fashion. A large red vein was noted superficially and coursed anterior-inferiorly toward the Sylvian fissure. A right temporal lobectomy was performed, measuring 5 cm posterior to the temporal tip. The parenchyma was noted to be very friable. The hematoma was removed, and there were no intraoperative complications. As the brain was decompressed, the red superficial vein normalized to the typical blue color commonly encountered. A postoperative angiogram was performed and demonstrated no vascular lesion as well as a normal alignment of the middle cerebral artery as is seen in Figure .\nPostoperative imaging is shown in Figure , which demonstrates good decompression and highlights the appropriate size of the craniectomy.\nHistopathological studies are shown in Figure and are consistent with herpes encephalitis, showing perivascular lymphocytic infiltrate, neuronophagia, and hemorrhage.\nShe had no postoperative complications and completed a three-week course of acyclovir. She was discharged to acute rehab with plans to return at a later date for cranioplasty.