Abstract Ref Number = APCP1128
ISSUES IN DIAGNOSING AND MANAGING HERPES SIMPLEX ENCEPHALITIS (HSE) - A CASE SERIES
Ivan Riyanto Widjaja,Dicky Adi Putra,Marsha Zaneta,Angelina Armine Susanto Putri
Department of Child Health Koja General Hospital General Practitioner Koja General Hospital Department of Child Health, Tanjung Priok General Hospital
Background : HSE is challenging to diagnose, let alone to manage. Gold standard for establishing diagnosis is not widely available. Moreover, intravenous (IV) antiviral for treatment cannot always be obtained. Eventually delayed management can lead to irreversible neurological impairment. We present two cases of suspected HSE.
Case Presentation Summary : First patient was a 7 years old female, admitted with a chief complain of headache and vomiting for 5 days. One month prior to admission she had recurrent seizure and diagnosed with epilepsy. She was on valproic acid afterwards. During current hospitalization she developed personality changes, nightmares, hallucination, focal seizure, and subsequent decrease level of consciousness. Meningeal signs were absent. Brain magnetic resonance angiography showed empty delta sign in the right occipito-temporal region. Cerebrospinal fluid (CSF) analysis was within normal limit and electroencephalography (EEG) showed epileptiform wave in right temporal with delayed conduction, suggested viral encephalitis. Since the patient continued to deteriorate, she was then referred to a tertiary hospital, where she was diagnosed with HSE and given IV Acyclovir and also IV immunoglobulin. On follow up three months later, she had a significant residual neurologic deficit as sequelae of encephalitis. Our second patient is a 7 years old female admitted for complex partial febrile seizure and altered behavior. CSF analysis was within normal limit. Brain Computed Tomography revealed viral enhancement and EEG showed epileptiform wave in temporal region with delayed conduction, suggested viral encephalitis. IV Acyclovir was prescribed, but unfortunately not available. She was then discharged against medical advice.
Learning Points/Discussion : Diagnosing HSE is tricky since CSF Herpes Simplex Virus (HSV) Polymerase Chain Reaction (PCR) as the gold standard is not always available. Signs and symptoms are not pathognomonic in early stage while IV acyclovir cost is very high. Even if the clinical decision was made early, drug availability is also quite a predicament.
Keywords: Herpes simplex encephalitis Acyclovir Neurologic deficit