Encephalitis due to human herpes simplex virus - Acute
Rahul Soman, M. Pharm
Definition
An acute, focal, necrotizing encephalitis with inflammation and swelling of the brain caused by herpes simplex virus (HSV) type 1 or type 2
Medical History
* Herpes simplex [Herpes simplex - Acute]
Findings
* Decreased level of consciousness - Acute
* Fever
* Headache
* Personality change
* Seizure
* Ataxia
* Hemiparesis
* Cranial nerve disorder
* Asthenia
* Aphasia
* Visual field defect
* Sensory disorder
* Vomiting
* Irritability
* Tremor
* Feeding problems in newborn
* Bulging fontanelle
Tests
Suspected herpes simplex encephalitis
* Herpes simplex virus DNA assay: A positive polymerase chain reaction test for herpes simplex virus (HSV) in cerebrospinal fluid is generally diagnostic of HSV encephalitis .
Suspected herpes encephalitis
* Cerebrospinal fluid examination: In herpes simplex encephalitis, the cerebrospinal fluid often shows lymphocytic pleocytosis, mildly elevated protein , and normal glucose levels .
Suspected and known herpes simplex encephalitis
* Magnetic resonance imaging of brain and brain stem: A cranial MRI showing a hemorrhagic encephalitis affecting the temporal and inferior frontal lobes strongly suggests herpes simplex virus encephalitis .
Suspected or known herpes simplex encephalitis
* Computerized axial tomography of brain: Although the brain CT may be normal early in the course of herpes simplex encephalitis, typical findings include lesions in one or both temporal lobes .
Suspected herpes simplex virus encephalitis
* Electroencephalogram: An EEG done early in the course of herpes simplex encephalitis may reveal periodic lateralized epileptiform discharges localized to the temporal lobes .
Suspected herpes simplex encephalitis
* Biopsy of brain tissue
Suspected herpes simplex encephalitis
* Herpes simplex virus 1 AND 2 antibody assay: Tests of cerebrospinal fluid for herpes simplex virus (HSV) antibodies may be useful after a week of therapy for HSV encephalitis, but HSV polymerase chain reaction (PCR) is recommended for diagnosis .
Suspected herpes virus infection of the central nervous system
* Herpes simplex virus culture: Herpes simplex virus (HSV) culture of cerebrospinal fluid is only useful in patients less than 6 months of age with suspected herpes simplex viral infection of the CNS .
Differential Diagnosis
* Viral encephalitis - Acute
* Abscess of brain - Acute
* Encephalopathy
* Meningitis
* Disseminated encephalomyelitis, acute
* Vascular disorder
* Intracranial tumor
* Subdural hematoma - Acute
* Adrenoleukodystrophy
* Systemic lupus erythematosus
Treatment
Drug Therapy
Suspected or known herpes simplex encephalitis
ACYCLOVIR
Adults: 10 mg/kg IV every 8 hours for 14 to 21 days
Pediatrics: 10 mg/kg IV every 8 hours for 14 to 21 days
Neonates: 20 mg/kg IV every 8 hours for 21 days
Acute control of focal or generalized seizures
LORAZEPAM
Adults: 4 mg IV at rate of 2 mg/minute; may repeat dose in 10 to 15 minutes if needed
Pediatrics: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes; may repeat one time in 10 to 15 minutes at 0.05 mg/kg
Neonates: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes; may repeat one time in 10 to 15 minutes at 0.05 mg/kg
PHENOBARBITAL SODIUM
Adults: 100 to 320 mg slow IV injection, not to exceed 600 mg/24 hours
Pediatrics: 15 to 20 mg/kg IV; may give additional doses of 5 mg/kg every 15 to 30 minutes to a maximum total dose of 30 mg/kg
Neonates: 20 mg/kg IV; follow with additional IV boluses of 5 mg/kg to a maximum total of 40 mg/kg
FOSPHENYTOIN SODIUM
Adults: 15 to 20 mg/kg IV, slowly at 150 mg/minute
Pediatrics: 15 to 20 mg/kg IV, slowly at 3 mg/kg/minute, maximum 150 mg/minute
Neonates: 20 mg/kg IV
PHENYTOIN SODIUM
Adults: 15 to 20 mg/kg IV, slowly at 150 mg/minute
Pediatrics: 15 to 20 mg/kg IV, slowly at 3 mg/kg/minute, maximum 150 mg/minute
Increased intracranial pressure
MANNITOL
Adults: 0.25 to 1 g/kg IV over 20 to 30 minutes; may repeat in 6 hours; maximum 6 g/kg/24 hours
Pediatrics: 0.25 g/kg IV over 20 to 30 minutes; may gradually increase to 1 g/kg/dose if needed
Procedural Therapy
Increased intracranial pressure
* Intracranial pressure monitoring: Cerebral perfusion is assessed by monitoring the intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and brain tissue PO2.
Increased intracranial pressure
* Decompression of brain: Mechanical decompression of the brain can be lifesaving when performed in a timely fashion in patients with herniation secondary to cerebral edema .
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