HSV in Older Children

1Washington University School of Medicine, St. Louis, MO
2Washington University School of Medicine, St. Louis, MO

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 219

Case Presentation:

This is a 2‐year‐old female who presented in status epilepticus with a fever. She had no previous history of seizures. She was stabilized and loaded with AEDs, and treated with empiric antibiotic therapy for presumed meningitis. She was started on empiric acyclovir after lumbar puncture. The acyclovir was discontinued when the HSV PCR was negative. CSF was also negative for bacterial studies, and antibiotics were discontinued. An EEG revealed epileptiform discharges. She remained in the hospital for 1 week demonstrating some residual left‐sided weakness, but was discharged home. Three days later she was readmitted with a fever and emesis. The evening of readmission she had a prolonged seizure, control of which resulted in respiratory depression requiring intubation. An MRI revealed a large area of edema with multiple hemorrhages. A repeat lumbar puncture was not possible because of her significant cerebral edema. Unremarkable diagnostic studies included ANA, C3, C4, arbovirus panel, Bartonella titers. Mycoplasma PCR, and CSF EBV, VZV and CMV. There was moderate serum lymphocytosis. MTHFR mutation was positive, but the hyperccagulable workup was otherwise negative. EBV and HHV6 PCR in the blood were positive. It was thought That these represented reactivation infection rather than the cause of her presentation. Ultimately, a brain biopsy was performed, which revealed glial nodules consistent with viral encephalitis. Neuropathology stains of the biopsy were positive for HSV. Electron microscopy showed particles consistent with HSV infection. The patient Improved quickly on acyclovir therapy and steroids. AT discharge she was able to walk without assistance. Repeat CSF HSV PCR and bacterial cultures were negative 1 month after initial presentation. She was discharged on oral acyclovir. Now, 2.5 years after initial presentation, the patient is doing well in main‐stream kindergarten. She has a seizure disorder that is medication controlled and minor extremity weakness that does not limit her mobility. She is maintained on oral acyclovir.

Discussion:

Although HSV encephalitis is usually included in the differential diagnosis of newborns with fever and seizure, clinicians often omit this diagnosis in older children presenting with similar symptoms. Since HSV is a treatable infection, early initiation of acyclovir can positively affect the outcome. Antiviral therapy should be empirically started on children presenting with symptoms of encephalitis. HSV PCR on CSF is a sensitive and specific method of diagnosis, however brain biopsy remains the gold standard.

Conclusions:

We present this case to illustrate the rare but devastating clinical course of HSV encephalitis in patients outside of the neonatal period. A negative HSV PCR result should not exclude this treatable diagnosis. For this reason, clinicians need to have a high index of suspicion.

Author Disclosure:

K. Berchelmann, none; P. Shah, none.

To cite this abstract:

Berchelmann K, Shah P. HSV in Older Children. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 219. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/hsv-in-older-children/. Accessed July 17, 2019.

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