Lost by the Wayside

Peter Lazzopina, MD, Frank Escobedo, MD, and Jose Ledezma, MD

A 68 year old male smoker with a past medical history significant for controlled hypertension and diabetes mellitus type 2 presented to our emergency department with a 5 day history of fevers, headache, body aches and upper respiratory infection symptoms. The patient lived alone and was recently elected to a public office in his small town but his family noted that he had become increasingly confused since his illness started.  On the day of presentation, he had been found by police on a roadside near his vehicle apparently confused and over 50 miles from his home.  Family noted that the patient had also been complaining of alterations in his visual perception, seeing shadows and blurred images which were not apparent to others.

Exam revealed a febrile patient with elevated blood pressure but otherwise normal vital signs.  He was oriented to person only but had no other neurologic deficits. Meningeal signs were absent. The rest of his examination was normal.

Labs and Rads as follows:

Influenza B positive by nasopharyngeal swab

WBC 13.6

Urinalysis significant for > 1000 glucose, negative for ketones and with 5 red blood cells per high powered field.

Serum chemistries normal except for glucose at 307

Chest x-ray showed mild bilateral patchy interstitial infiltrates

CT head was significant for cerebral atrophy and nonspecific white matter changes.

Lumbar puncture with cerebrospinal protein at 77 mcg/dl (reference range 15-45) and glucose 143 mg/dL (reference range 45-75). Other CSF analyses were pending at the time of admission.

Our patient was admitted with influenza, secondary bacterial community acquired pneumonia and delirium.  Treatment included oseltamivir, ceftriaxone and azithromycin.  As we admitted the patient, family members questioned: “Are you sure it’s just the flu?  He’s never been confused before.” Having seen lots of sick and confused elderly people before, I confidently asserted that we would start to see some improvement in the next day or so.

The following day the patient spiked a fever in the early morning and remained delirious with alternating bouts of confusion and periods of partial lucidity.  CSF RBC: 64 and CSF WBC: 290 (90% lymphocytes).  Acyclovir was started for HSV encephalitis and an MRI of the brain was obtained.

Figure: Diffusion weighted MRI of the brain. Note the classic temporal lobe distribution of inflammation and edema characteristic of HSV encephalitis.

 

 

 

Thirty six hours following initiation of treatment with acyclovir the patient was afebrile and oriented to person, place and time.  He even recalled the current president of the United States.  The CSF subsequently returned positive for HSV-1 RNA by PCR.  The patient recovered steadily and was eventually discharged to a rehab facility with some persistent cognitive slowing.

In hindsight, the diagnosis seems clear.  HSV encephalitis should be considered in any febrile encephalopathic patient with focal neurologic problems on exam.  The diagnosis was appropriately entertained and a lumbar puncture was performed.  However, the result of other data led us to believe that we had a slam dunk diagnosis of influenza pneumonia and a reasonable explanation for our patient’s confusion.  The take home point is that once the diagnosis of HSV encephalitis is entertained and a lumbar puncture is obtained the patient should be started on IV acyclovir until the CSF results prove absence of HSV infection.  The low risk of acyclovir induced renal injury can be reduced with adequate hydration and slow infusion.  The upside is a significant reduction in HSV related morbidity and mortality.

One final note: When this patient was presented at our daily conference, we thought we had a fantastic case with a real twist for our audience that would take everyone by surprise.  As the resident began his presentation with “A 68 year old male was found wandering the roadside near his vehicle by the police…” one of my more experienced colleagues leaned over and whispered matter of factly, “HSV encephalitis.”

Astonished, I questioned, “Who told you about the case?”

“No one.  The other two cases of HSV encephalitis we’ve had here started with a patient wandering the roadside far from their homes.” With my jaw still hanging, we leave you with one final tip: For patients lost by the wayside – think HSV Encephalitis!

References:

Levitz RE. Herpes simplex encephalitis: a review. Heart Lung. 1998;27(3):209.

Raschilas F. Outcome of and prognostic factors for herpes simplex encephalitis in adult patients: results of a multicenter study. Clin Infect Dis. 2002;35(3):254.

 

 

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