Brain stem encephalitis caused by primary herpes simplex 2 infection in a young woman.
A 27 year old woman developed a vesicular genital rash and cerebellar dysfunction with progressive neurological deterioration suggesting brain stem encephalitis. Respiratory support was required. Magnetic resonance imaging (MRI) of the brain on day 7 showed signal hyperintensity in the central medulla and ventral pons, typical of acute inflammation. The course was severe and relapse occurred. MRI on day 33 showed a haemorrhagic area in the medulla. Treatment with aciclovir/valaciclovir eventually led to gradual recovery. Herpes simplex virus 2 (HSV-2) DNA was detected in CSF on days 11 and 14. HSV-2 was also detected in vesicle fluid from the genital rash. Serum was initially negative for HSV-1 and HSV-2 antibodies, but convalescent samples showed seroconversion to HSV-2, indicating primary infection. Intrathecal synthesis of oligoclonal IgG bands specific for HSV was identified in the CSF. It is important to differentiate HSV-2 from HSV-1, and primary from initial or reactivated infection, so that prolonged aciclovir treatment followed by prophylaxis is instituted to prevent the high likelihood of symptomatic relapse in primary HSV-2 infection.
Tang
J W
JW
Department of Virology, Royal Free and University College Medical School, Cleveland Street, London W1, UK.
Coward
L J
LJ
Davies
N W S
NW
Geretti
A M
AM
Howard
R S
RS
Hirsch
N P
NP
Ward
K N
KN
D000212:Acyclovir / Q000627:therapeutic use; D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use; D001933:Brain Stem / Q000473:pathology* / Q000821:virology; D004279:DNA, Viral / Q000032:analysis; D020803:Encephalitis, Herpes Simplex / Q000188:drug therapy / Q000473:pathology*; D005260:Female; D018258:Herpesvirus 2, Human / Q000472:pathogenicity*; D006801:Humans; D007074:Immunoglobulin G / Q000032:analysis; D008279:Magnetic Resonance Imaging
D000998:Antiviral Agents; D004279:DNA, Viral; D007074:Immunoglobulin G; D000212:Acyclovir