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Subtle Presentation of Herpes Simplex Encephalitis

Abstract Herpes Simplex Encephalitis (HSE), while relatively rare, is of relevance to the emergency medicine provider due to its destructive, rapid progression and its often unexpected and sudden onset. We present a case of an older man who arrived at the ED with a mild fever (100.1oF ), and an insi...

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Bibliographic Details
Published in:The American journal of emergency medicine 2017-01, Vol.35 (1), p.200.e1-200.e2
Main Authors: Croll, Benjamin J., BS, Dillon, Zachary M., MD, Weaver, Kevin R., DO, Greenberg, Marna Rayl, DO MPH
Format: Article
Language:English
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Summary:Abstract Herpes Simplex Encephalitis (HSE), while relatively rare, is of relevance to the emergency medicine provider due to its destructive, rapid progression and its often unexpected and sudden onset. We present a case of an older man who arrived at the ED with a mild fever (100.1oF ), and an insidious weeklong onset of increasing fatigue and anorexia in the context of chronic hypertension, diarrhea, anxiety, depression and baseline mild bilateral hand tremors. Urinalysis revealed moderate blood, and complete blood count showed leukocytosis, which lead to the tentative diagnosis of a urinary tract infection with secondary diagnoses of depression and fatigue. He was instructed to follow up with his primary care provider (PCP) the following day. In follow-up the patient had new onset memory loss and confusion and an MRI ordered by the PCP revealed abnormal signal enhancement of the left temporal lobe compatible with herpes encephalitis. The patient was admitted, and the diagnosis was supported by CSF lymphocyte pleocytosis and later confirmed by viral PCR. The patient was treated with acyclovir and was discharged five days after admission. At discharge, he stated feeling better, but had some residual mild confusion and general weakness. Because of the severity of the disease's progression, its lack of predictability, and the risks of delay in diagnosis, it is imperative that it be given consideration in the clinician's differential diagnosis.
ISSN:0735-6757
1532-8171
DOI:10.1016/j.ajem.2016.07.045