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Herpes simplex virus encephalitis in a patient receiving ustekinumab associated with extensive cerebral oedema and brainshift successfully treated by immunosuppression with dexamethasone
  1. Harriet Kay Van Den Tooren1,
  2. Viraj Bharambe1,
  3. Nicholas Silver1 and
  4. Benedict D Michael1,2
  1. 1 Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
  2. 2 Department of Clinical Infection Microbiology and Immunology, Institute of Infection and Global Health, Liverpool, UK
  1. Correspondence to Dr Benedict D Michael, benedict.michael{at}


Herpes simplex virus (HSV) encephalitis affects 2–4 people per million/year. Immunocompomised patients can have atypical presentations of HSV encephalitis, including a lack of cerebrospinal fluid (CSF) pleocytosis. We present the case of a patient who was receiving ustekinumab therapy for psoriasis which inhibits interleukin (IL)-12 and IL-23 signalling pathways. The initial presentation was suggestive of encephalitis, but he was discharged prior to the reporting of HSV positivity due to the lack of CSF pleocytosis. On representation, he had worsening symptoms and imaging showed midline shift, indicating cerebral oedema despite the immunosupressant effects of ustekinumab. He required intensive care unit support and treatment with high dose aciclovir and dexamethasone; after a month of treatment he made a good recovery. This case is the first to report a link between ustekinumab and HSV encephalitis, and also emphasises that imunocompromised patients can lack CSF pleocytosis and develop significant cerebral oedema which responds to immune suppression.

  • skin
  • neuro itu
  • infection (neurology)
  • unwanted effects/adverse reactions
  • infections
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  • Contributors BDM conceived the idea of writing this case to be published. BDM, NS and VB were involved in the planning of the case report. HKVDT collected the clinical data and drafted the report. HKVDT, BDM, NS and VB all reviewed and made critical revisions to the drafted report. All authors gave final approval of the report prior to submission.

  • Funding BDM is supported by the NIHR HPRU for Emerging and Zoonotic Infection and the NIHR EME ISRCTN11774734.

  • Competing interests BDM reports grants from National Institute of Heath Research, grants from Welcome Trust, grants from Academy of Medical Sciences, grants from British Medical Association, grants from British Infection Association, outside the submitted work. NS reports personal fees from Novatis, personal fees from Eli Lilly, personal fees from Teva, personal fees from Allergan, personal fees from Electrocore, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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