METHODS (DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS AND TREATMENT)
Diagnostic workup included imaging and CSF studies. At the first center, CSF analysis results indicated a viral etiology, characterized by total leucocyte count – 10 per high power field constituted by 98% lymphocytes with sugar level – 20 mg/dl, elevated protein - 79 mg/dl and normal ADA.
Computed Tomography scan at the second center revealed bilateral asymmetric hypodensities, predominantly on the left side, affecting the cortex, antero-inferior temporal lobe, and infero-lateral lobes. Repeat lumbar puncture report was positive for both Herpes Simplex Virus (HSV) and Epstein-Barr Virus (EBV) confirmed with polymerase chain reaction.
MR Imaging at our center revealed ill-defined T2/FLAIR lesions in the bilateral insular cortex, bilateral superior temporal gyri, and bilateral precentral gyrus involving both grey and white matter of frontoparietal lobes (left > right), features that were suggestive of sequelae of Fiox-Chavany-Marie syndrome secondary to herpes simplex encephalitis.
Antiviral therapy (Acyclovir- 500 mg intravenous three times a day) was initiated at the second center where CSF-PCR showed Herpes simplex, which was continued at our center covering total duration of 28 days. A tracheostomy tube was electively inserted to facilitate respiratory support. Besides antiviral therapy, other supportive treatments were given to address complications such as hospital-acquired pneumonia and respiratory distress.