Case Report: In-hospital herpes simplex encephalitis after open heart surgery: an emerging pathology or an under-recognised condition?

Case Report: In-hospital herpes simplex encephalitis after open heart surgery: an emerging pathology or an under-recognised condition?

Spontaneous schwannomas were detected by magnetic resonance imaging (MRI) in a transgenic murine model of neurofibromatosis type 2 (NF2) expressing a dominant mutant form of merlin under the Schwann cell-specific P0 promoter. An MRI-based reporter gene enables monitoring of gene expression in the deep tissues of living subjects. Cerebrospinal fluid examination revealed an elevated mononuclear cell count with normal sugar concentration. We also review the literature on MRI changes in paralytic rabies. Herpes simplex encephalitis (HSE) is one of the most severe viral infections affecting the temporal lobes of the brain. Contrast enhancement, particularly of the involved cortex, occurs in the later stages and meningeal enhancement may also be present. Varicella zoster virus AI also showed a correlation with T2 lesion load on cMRI but did not reach statistical significance (p = 0.2893).

CONCLUSIONS These results confirm the previously reported association between viral infections and multiple sclerosis exacerbations and indicate that the relative risk may be even higher when viral infection is serologically confirmed. There were no remarkable pre- or perinatal antecedents. All other investigations were normal. Human to human transmission is rare, but there have been cases of infection occurring transplacentally, via breast feeding, from blood transfusions and following organ transplantation. Even though microcephaly is the principal characteristic of a severe congenital infection during the early stages of pregnancy, to the best of our knowledge, the radiological features of children with presumed Zika virus related congenital infection or microcephaly have not been well characterised. The patient needed mechanical ventilation because of septic shock-related encephalopathy. Registration is free.

Inactivation of the NF2 protein product occurs in both sporadic and familial schwannomas and meningiomas, supporting the NF2 gene as a tumor suppressor gene [9–13]. Ultrasound control of renal allograft showed no vascular or obstructive abnormalities. The CSF protein and glucose concentrations were 68 and 50 mg/dL, respectively, and Gram’s stain showed no bacteria. She was receiving a combination therapy including valproate, carbamazepine, levetiracetam, lamotrigine and biperidene before admission. On the 10th postoperative day his state of consciousness altered and rapidly progressed to coma associated with fever and septic shock necessitating mechanical ventilation and circulatory support by norepinephrine. No biological findings could explain this coma. Otherwise he had no other remarkable medical condition.

Case Report: In-hospital herpes simplex encephalitis after open heart surgery: an emerging pathology or an under-recognised condition?
He had an emergency aortocoronary bypass surgery for an acute myocardial infarction. The surgery consisted of four venous grafts between coronary network and ascending aorta. The surgery was uneventful and the patient was weaned from mechanical ventilation immediately after surgery. He became progressively encephalopathic on 6 th day of illness and had a cardio-respiratory arrest on 16 th day. He was admitted in our ICU for management. On admission his temperature was 39°C, arterial blood pressure was maintained at 120/90 mm Hg by epinephrine 0.5 mg/h. Additionally, 44 patients in the group underwent spinal MRI.

If the pattern of reactivity within the panel changed from negative to positive, then the four samples temporally spanning this change were retested and titred accurately by twofold dilutions. Unremarkable cranial MRI findings are seen in ataxia–opsoclonus syndrome, Sydenham chorea, and encephalitis lethargica (three probably immunomediated encephalopathies with prominent extrapyramidal signs),7–9 suggesting a more functional and less structural abnormality. The patient was already treated by piperacillin–tazobactam and amikacin. On the fifth day of admission he was weaned from mechanical ventilation and epinephrine. Cerebrospinal fluid samples from six children were tested by IgM antibody capture enzyme-linked immunosorbent assay (the new specific test for Zika virus), following the protocol of the Centers for Disease Control and Prevention.19 Genetic testing is not included in the Brazilian government’s protocol, and differential diagnosis is performed based on family history and imaging findings, as is done with all metabolic diseases. There were no explanation for his condition and no clinical or laboratory signs of sepsis. The recurrent tumor was resected and a Rickham reservoir was inserted to allow infusion of genetically engineered autologous CD8+ cytolytic T cells (CTLs).

Because MRI can provide information about in vivo tumor metabolism and pathophysiology nondestructively, preclinical results from animal models may be applied in clinical settings [23]. The patient’s mental status still remained abnormal. After 6 months of follow-up, the patient and newborn were in good health. But atypical CT findings may be confusable in HSVE. CSF proteins and CSF glucose levels were normal. Gram stain was negative. The patient received acyclovir intravenous infusion.

Brain CT was normal. Brain MRI was performed on the ninth day of admission and was normal. Lumbar puncture was performed on the ninth day of admission; it showed no cellular elements and CSF proteins and glucose levels were normal. Gram stain and bacterial culture were negative but herpes simplex type 1 was detected in large amounts by PCR in CSF. Four days after acyclovir treatment the patient recovered with a normal neurological status with no sequelae; he was weaned from catecholamine and mechanical ventilation, and was discharged. Antiviral treatment was pursued for 21 days. In reviewing 432 patients with presumptive HSV encephalitis and by searching for virus via brain biopsy and comparing biopsy findings with CSF findings in patients with biopsy-proven HSV encephalitis (195/432), Whitley et al10 found CSF abnormalities in nearly all patients (97%) and fever in 90% of cases.

The analysis was carried out with a manual thresholding technique using Analyze image analysis software on a Silicon Graphics workstation. This unique finding highlights the importance of clinical presumption and the role of molecular biology in establishing HSV encephalitis. In the context of cardiopulmonary bypass, herpes simplex virus (HSV) encephalitis should be ruled out once unexplained postoperative altered mental status or behaviour develops before talking about delirium because any delay in antiviral treatment influences neurological outcome.

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