RT Journal Article
SR Electronic
T1 Herpes simplex virus encephalitis in a patient receiving ustekinumab associated with extensive cerebral oedema and brainshift successfully treated by immunosuppression with dexamethasone
JF BMJ Case Reports
JO BMJ Case Reports
FD BMJ Publishing Group Ltd
SP e229468
DO 10.1136/bcr-2019-229468
VO 12
IS 8
A1 Harriet Kay Van Den Tooren
A1 Viraj Bharambe
A1 Nicholas Silver
A1 Benedict D Michael
YR 2019
UL http://casereports.bmj.com/content/12/8/e229468.abstract
AB 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.