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Case Reports: Learning from unexpected outcome (positive or negative)
Herpetic encephalitis with autoimmune recurrence following cerebral aneurysm clipping
  1. Joana Moniz Dionísio1,2,
  2. Mariana Santos2,
  3. Alexandra Seromenho-Santos3,4 and
  4. Carla Reizinho3
  1. 1Neurosurgery, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
  2. 2Neurology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, Portugal
  3. 3Neurosurgery, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
  4. 4Instituto de Anatomia, Universidade de Lisboa Faculdade de Medicina, Lisboa, Portugal
  1. Correspondence to Dr Joana Moniz Dionísio; joanamonizdionisio{at}gmail.com

Abstract

A man in his late 60s with well-controlled HIV underwent an uneventful surgical clipping of an unruptured intracranial aneurism. Postoperatively, he developed fever, seizures and an altered mental status. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, high protein count and a positive herpes simplex virus (HSV)-2 PCR. Acyclovir was started. Brain MRI showed right hemisphere T2/FLAIR-weighted anterior temporal cortical and subcortical hyperintensities. After 2 months, he developed psychosis, an upper limb tremor and pyramidal tract dysfunction. A new brain MRI revealed a new right frontal white matter lesion, extending to the corpus callosum. Anti-N-methyl-D-aspartate receptor (NMDAR) antibodies were positive in CSF, while there was no evidence of active HSV infection. Methylprednisolone and IVIg were started, and a significant clinical improvement was achieved.

If an unknown inflammatory process occurs after surgery, herpetic encephalitis should be considered, and treatment should be initiated precociously. Since herpetic encephalitis can trigger an anti-NMDAR encephalitis, this autoimmune complication must be considered.

  • Neurosurgery
  • Neurological injury
  • Infection (neurology)

https://doi.org/10.1136/bcr-2022-248896

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    Footnotes

    • Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: JMD, MS, ASS and CR. The following authors gave final approval of the manuscript: JMD, MS, ASS and CR. JMD is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

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