A 23‐year‐old woman with a 24‐week pregnancy presented to the ED with complaints of a progressively worsening headache of 2 weeks' duration. The headache was frontal, pounding in nature, rated 10/10 in severity, and associated with nausea, vomiting, and photophobia. Her medical history was significant for migraine headache. Vital signs were significant for tachycardia, but blood pressure was within normal limits. Physical exam showed a gravid woman who was uncooperative and in moderate distress because of the headache. No focal neurological abnormalities were noted. Laboratory tests showed leukocytosis and proteinuria. The patient was admitted to rule out preeclampsia, and treatment was begun to abort the headache. The patient became febrile and started to seize. Antiepileptic management was begun, and an MRI of the brain showed a subarachnoid hemorrhage in the right frontal and temporoparietal regions. This clinical picture raised the suspicion for herpes encephalitis. Empiric therapy was begun with acyclovir, and a lumbar puncture was performed, confirming the diagnosis with a positive PCR of HSV‐1. The patient completed a 14‐day course of IV acyclovir, and her mental status returned to baseline. The remainder of her pregnancy was uncomplicated, and she delivered at full term.
The classic presentation of preeclampsia consists of new‐onset hypertension in a previously normotensive woman with proteinuria or edema beyond the 20th week of gestation. Neurological symptoms may include headache, blurred vision, and altered mental status. Alternatively, there are patients who present without proteinuria (22%), edema (33%), or hypertension (16%). In these patients who present with neurological symptoms only the differential diagnosis expands to include migraine headaches, encephalitis, and meningitis. As soon as encephalitis in pregnancy is suspected, a combination of acyclovir and penicillin is recommended because the potential benefits far outweigh the risks. HSV encephalitis remains a significant cause of neurological impairment in pregnant women. Assessment of fetal contamination also remains a problem.
Delay in recognition and management of viral encephalitis in pregnancy is a significant cause of morbidity and mortality. Even with appropriate diagnosis and treatment, mortality may still be as high as 20% to 30%. Therefore, it is of utmost importance to include herpes encephalitis in the differential of a pregnant patient presenting with headache and altered mental status.
C. Pimentel, none.
To cite this abstract:Pimentel C, Carrington M, Pimentel‐Brugal E, Ramirez M, Frilingos D. Not Always Is Preeclampsia: Viral Encephalitis in Pregnancy. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 166. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/not-always-is-preeclampsia-viral-encephalitis-in-pregnancy/. Accessed September 22, 2019.