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Indian Pediatr 2015;52: 991 |
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Intracerebral Hematoma in an Infant with
Herpes Simplex Encephalitis
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*Venkateswari Ramesh
and Janani Sankar
Department of Pediatrics, CHILDS Trust Medical Research
Foundation,
Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India.
Email: * [email protected]
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Herpes simplex virus (HSV) encephalitis is a leading
cause of sporadic encephalitis in children [1]. Neurological findings
are mostly related to dysfunction of the fronto-temporal lobes.
Intracerebral hematoma complicating herpes encephalitis is unusual and
extremely rare in children.
A four-month-old developmentally normal male infant
with uneventful antenatal and neonatal period, on exclusive breast
feeds, was brought to us with history of low grade fever for two days
and recurrent brief episodes of focal seizure in the form of clonic
movements of upper limb with upward gaze and unresponsiveness. On
examination, infant was alert with no encephalopathy or focal
neurological deficit. Head circumference was 41.5 cm. Anterior
fontanelle was normal. Sepsis workup was non-contributory. CSF analysis
showed elevated protein (63 mg/dL), normal glucose (73 mg/dL), and 10
lymphocytes and 600 red blood cells per high power field. CSF HSV-1 DNA
PCR was positive. Initial MRI brain showed hemorrhage in bilateral
postcentral gyrus (left more than right) and restricted diffusion in
right thalamus, bilateral fronto-parietal regions, left posterior
temporal white matter and right insula. He was treated with acyclovir
and fosphenytoin. One week after admission, infant had recurrent brief
episodes of left focal seizure. Seizures were controlled with
leviteracetam and clinically infant remained stable with no
encephalopathy or neurological deficit. Repeat MRI brain showed subacute
intraparenchymal hematoma with adjacent edema in the bilateral
frontoparietal regions and insula and significant increase in hemorrhage
compared to previous scan. Baseline workup for bleeding diathesis (PT,
aPTT, screening for factor XIII deficiency) was normal. No neurosurgical
intervention was attempted, clinically, infant remained stable. Infant
was discharged on oral anticonvulsants, after completion of 3 weeks of
parenteral acyclovir. On follow up, at 11months of age, he is
developmentally normal with no focal deficit and no recurrence of
seizure.
Intracerebral hematoma complicating herpes
encephalitis has been reported in adults, but is rare in children [2].
The mechanism of hemorrhagic complication is unclear. Possible
mechanisms proposed include small vessel rupture secondary to vasculitis
and transient hypertension caused by raised intracranial pressure [3].
The lack of improvement or the worsening of initial symptoms,
particularly during the second week of admission, should lead to this
suspicion and to perform a neuroimaging study. A few patients have
required surgical intervention and over all prognosis is usually
favorable [4].
References
1. Lawrence R.Stanberry. Herpes simplex virus. In:
Kliegman RM, Stanton BF, St. Gema JW, Schor NF, Behrman RE, editors.
Nelson Textbook of Pediatrics, 19th edn. Philadelphia: WB Saunders Co,
2011. p. 1097-104.
2. Takeuchi S, Takasato Y. Herpes simplex virus
encephalitis complicated by intracerebral hematoma. Neurol India.
2011;59:594-6.
3. Fukushima Y, Tsuchimochi H, Hashimoto M, Yubi T,
Nakajima Y, Fukushima T, et al. A case of herpetic
meningoencephalitis associated with massive intracerebral hemorrhage
during acyclovir treatment: A rare complication. No Shinkei Geka.
2010;38:171-6.
4. Rodriguez-Sainz A, Escalza-Cortina I, Guio-Carrion
L, Matute-Nieves A, Gomez-Beldarrain M, Carbayo-Lozano G, et al.
Intracerebral hematoma complicating herpes simplex encephalitis. Clin
Neurol Neurosurg. 2013;115:2041-5.
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