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Requests for reprints should be addressed to Bernadette Tan Qiao Min, MBBS, Department of General Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886.
A previously well 69-year-old woman presented with 2 days of fever, headache, vomiting,
Broca aphasia, and upper respiratory tract symptoms. She was empirically treated for
meningoencephalitis with intravenous (IV) ceftriaxone, vancomycin, ampicillin, and
acyclovir after lumbar puncture was performed. Cerebrospinal fluid analysis showed
lymphocytic pleocytosis and positive herpes simplex virus polymerase chain reaction
(PCR) (Table). Initial computed tomography of the brain was normal. Magnetic resonance imaging
(MRI) of the brain findings are demonstrated in the Figure. The patient became increasingly confused and developed status epilepticus, and was
intubated and transferred to the intensive care unit. Her aphasia improved and she
remained seizure free. However, she continued to have low-grade temperature despite
21 days of IV acyclovir; hence, a repeat lumbar puncture was performed, which showed
persistent pleocytosis but negative herpes simplex virus PCR. Since day 38, she developed
receptive aphasia, auditory and visual hallucinations, and emotional lability. MRI
of the brain was repeated (Figure). A third cerebrospinal fluid analysis showed persistent pleocytosis (Table) and positive anti-N-methyl-d-aspartate (NMDA) receptor. She was treated for autoimmune encephalitis with IV methylprednisolone,
followed by IV immunoglobulin and a tapering dose of oral prednisolone, with clinical
and radiological improvement.
Figure(A, B, C) MRI of the brain on day 4 of admission, demonstrating swelling with T2 FLAIR hyperintensity
of the left (A) anterior and (B) medial temporal lobe and (C) left insula, and mild left basitemporal and insular leptomeningeal enhancement (not
shown); (D, E, F) Repeat MRI of the brain on day 41 demonstrating increased T2 FLAIR hyperintensity
of the left (D) anterior and (E) medial temporal lobe and (F) insula and new T2 FLAIR hyperintensity in the (F) left dorsomedial thalamus, with increased leptomeningeal enhancement of these areas
(not shown). FLAIR = fluid-attenuated inversion recovery; MRI = magnetic resonance
imaging.
Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis.
Conflicts of Interest: The authors certify that they have NO affiliations with, or involvement in, any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Authorship: We verify that all authors had access to the data and a role in writing the manuscript.
