Herpes Simplex Virus Central Nervous System Infection Presenting as a Stroke: Case Report

Introduction: Herpes simplex virus (HSV) encephalitis is a well-known fulminant infection, which oftentimes ends with permanent neurological deficits and sometimes death. While Cerebral infarction is considered a rare presentation of this infection. The case: An eight-year-old previously healthy girl presented with the clinical syndrome of upper respiratory tract infection. She later became hypoactive and experienced a seizure attack. The neurological examination revealed normal findings except for a notable reduction in motor power on the right side (one out of five) compared to the left (five out of five). Brain imaging showed an acute cortical infarction with a focus of hemorrhage in the left front-parietal medial cortex with diffuse leptomeningeal enhancement, suggestive of meningoencephalitis complicated by focal cortical infarct and hemorrhage. Empirical treatment with Ceftriaoxone, vancomycin, and acyclovir was initiated. By the third day of admission, her condition worsened, marked by multiple seizure events and decline in consciousness level, reflected in a decrease of her GSC to 8 out of 15. Lumbar puncture was initially delayed due to concerns of increased intracranial pressure. It was performed on the 6th day of hospitalization and confirmed a positive polymerase chain reaction (PCR) for Herpes simplex virus type 1. Because neurological deficits persisted, the necessity for additional therapy was raised, leading to a joint medical decision to initiate corticosteroid treatment. Dexamethasone therapy was initiated on day 7 of hospitalization dosed 0.6 mg per kilogram of body weight per day taken intravenously every six hours, was administered for a total of four days. Following steroid administration, the child's consciousness returned to normal, and motor function improved, and she received a total of 28 days of intravenous acyclovir. She was discharged with intact neurological function, albeit mildly reduced motor power in the right upper limbs only (three out of five). Discussion: Infections of the central nervous system caused by HSV can lead to various neurological complications. However, the acute presentation of cerebral infarction is considered rare. Some cases in the literature describe HSV encephalitis associated with hemorrhagic and ischemic strokes in pediatric patients. For instance, a sixteen-month-old female with proven HSV encephalitis exhibited paresis of the right hand as the first sign, caused by a left parietal lobe hemorrhagic stroke. Another case of a three-year-old child with bilateral occipital ischemic stroke and detected HSV PCR in serum and CSF. (picture). Current guidelines from the IDSA recommend acyclovir for treating HSV CNS infection, while the role of steroids remains controversial due to limited evidence supporting their use. A retrospective study of 45 adults with HSV encephalitis identified older age, low GCS at the time of acyclovir initiation, and failure to start steroids at presentation as factors associated with death or severe neurologic deficits. An ongoing multi-center, randomized controlled trial is assessing the clinical outcomes of dexamethasone alongside acyclovir compared to acyclovir alone in the treatment of HSV encephalitis. The results of this study will likely contribute to further understanding the efficacy of steroid on clinical outcomes. In pediatrics, there is no randomized trial that examined the effectiveness of such an intervention.