Hospital: COMPLEJO ASISTENCIAL UNIVERSITARIO DE LEON.
Nº: C2019-183
Aut@r o Autores: I.M. Lopez Garcia, F.J. Somalo Alfaro, A. Perez Termenón, M.M. Valle Franco, L. Martinez Gonzalez, M. Suarez Pereiro.
Presentación
We present the case of a 48-year-old man who presented at the emergency department with a clinical course of 3 days of fever, frontal headache, disorientation, and convulsions. The patient was evaluated through a complete neurological anamnesis and an urgent CT was requested to perform a differential diagnosis focused on the inflammatory pathology of the central nervous system. The initial diagnosis was herpetic encephalitis.The brain CT showed hypodensity of the left mesial temporal lobe in relation to herpetic encephalitis and complication with left temporal hemorrhagic hematoma. Coronal CT reconstruction of the orbits after 10 days of diagnostic, where we observed thickening of the superior ophthalmic vein (arrows) in relation to cavernous sinus thrombosis.
Discusión
CT is the initial neuroimaging study since it offers a rapid evaluation that allows excluding space-occupying lesions or cerebral edema, which increase intracranial pressure and contraindicate a lumbar puncture. In the acute stage, the initial CT scan could be negative or non-specific with imitation of other etiologies, but it may show typical lesions in approximately 25-80% of patients. A patient with a negative initial CT will probably show radiological lesions on a second CT scan. The radiological findings are characterized by bilateral and asymmetric affectation with hypodensities in mesial temporal lobe, lower frontal cortex and gyrus insulae, local mass effect, and absence of hypodensities in basal ganglia. The most common complications are hemorrhage near the hypodense area, brain edema, and herniation. MRI should be done to visualized betterpathognomonic brain lesions. A PCR of CSF for herpes simplex virus type 1 confirms the diagnosis. Early treatment with acyclovir will influence on morbidity and mortality of these patients, hence the importance of an initial approach with radiological diagnostic techniques.
Conclusión
We present a case report of a patient with herpetic encephalitis, who presented necrotizing hemorrhagic transformation and cavernous sinus thrombosis.CT should be the initial neuroimaging study because it guides the diagnose suggesting viral encephalitis, may suggest an alternative diagnosis and confirms the contraindication of a lumbar puncture.
Bibliografía
- Chow FC, et al. Use of clinical and neuroimaging characteristics to distinguish temporal lobe herpes simplex encephalitis from its mimics. Clin Infect Dis. 2015, 60(9):1377-1383. - Suli U, et al. Herpex simplex virus encephalitis: clinical manifestation