warfarin and Encephalitis--Herpes-Simplex

We report a case of classic HSE with early neurological relapse 7 days after onset of acyclovir treatment secondary to cerebral venous thrombosis (CVT). The development of CVT after meningoencephalitis has been described with neurotropic viruses such as HSV, HIV, or enteroviruses and also bacterial or fungal agents. CVT is probably the consequence of the inflammation secondary to these infections. A diagnosis of CVT, although rarely described, should be systematically suspected in patients with HSE who present no or only moderate improvement, or early relapse of symptoms despite adapted acyclovir treatment.

Topics: Acyclovir; Anticoagulants; Antiviral Agents; Encephalitis, Herpes Simplex; Female; Humans; Middle Aged; Sinus Thrombosis, Intracranial; Warfarin

We present a case of cerebral venous sinus thrombosis (CVST) as a rare complication of herpes simplex virus (HSV) encephalitis. A young man with no pertinent medical history was diagnosed with HSV encephalitis. After initial treatment, he showed improvement in symptomatology until day 6 when he acutely developed new neurological deficits. An urgent MRI brain showed changes in left temporal lobe consistent with HSV encephalitis and lack of flow void in superior sagittal sinus. Subsequent magnetic resonance venography confirmed the diagnosis of superior sagittal sinus thrombosis along with thrombosis of bilateral frontoparietal cortical draining veins. Anticoagulation was immediately initiated and oral anticoagulation was continued for 1 year. He made complete recovery subsequently. Our case serves as a reminder for the treating clinicians to consider CVST in patients with HSV encephalitis who develop an unexpected new neurological deficits during early phase of appropriate treatment.

Topics: Acyclovir; Adult; Anticoagulants; Antiviral Agents; Cerebral Veins; Diagnosis, Differential; Encephalitis, Herpes Simplex; Heparin; Humans; Hydrocephalus; Magnetic Resonance Imaging; Male; Simplexvirus; Superior Sagittal Sinus; Temporal Lobe; Venous Thrombosis; Warfarin

Cerebral venous thrombosis (CVT) is an uncommon but serious type of stroke. Thrombosis may involve the cortical or deep veins or the venous sinuses. The presenting clinical features are non-specific. We report a 48-year-old man with CVT who presented with fever, bitemporal throbbing headache, and generalised convulsion. Computed tomography (CT) of the brain revealed acute haemorrhages over right anterior frontal and posterior temporal regions with surrounding oedema and right anterior temporal subcortical oedema. The initial diagnosis was herpes simplex encephalitis. Absence of venous flow over the right transverse and sigmoid sinuses during the venous phase of digital subtraction angiography (DSA) revealed CVT. He was anti-coagulated for 6 months. An underlying cause of CVT was not detected. A high index of suspicion is required when risk factors of CVT are present. CT brain may be normal or showing non-specific findings. Magnetic resonance imaging plus venography, CT venography, or DSA is diagnostic.

Topics: Angiography, Digital Subtraction; Anticoagulants; Brain; Diagnosis, Differential; Encephalitis, Herpes Simplex; Fever; Frontal Lobe; Heparin, Low-Molecular-Weight; Humans; Intracranial Hemorrhages; Intracranial Thrombosis; Male; Middle Aged; Seizures; Temporal Lobe; Tomography, X-Ray Computed; Venous Thrombosis; Warfarin