A retrospective analysis of forty-six cases of herpes simplex encephalitis seen in Glasgow between 1962 and 1985

Kennedy, P. G. E. (1988) A retrospective analysis of forty-six cases of herpes simplex encephalitis seen in Glasgow between 1962 and 1985. QJM: An International Journal of Medicine, 68(255), pp. 533-40.

Abstract

The clinical features, investigative profiles and outcome of 46 patients with biopsy or autopsy-proven herpes simplex encephalitis admitted to the Institute of Neurological Sciences, Glasgow between 1962 and 1985 were analysed retrospectively. The protean presenting symptoms and signs included a history of a prodromal influenza-like illness (48 per cent), rapid onset of headache, clouding of consciousness and confusion (52 per cent), meningism (65 per cent), raised intracranial pressure (33 per cent), deep coma (35 per cent), mutism or aphasia (46 per cent), focal neurological signs (89 per cent), and seizures (61 per cent). When seizures occurred they were almost always focal. The electroencephalogram was the most useful diagnostic test being abnormal in all cases, the majority showing focal changes in one or other hemisphere. Of the neuroradiological procedures employed, computerized tomographic and isotope brain scanning most frequently demonstrated localizing abnormalities in one or both temporal and/or frontal lobes. Midline shift was seen in half the cases. The cerebrospinal fluid was abnormal in every case but was not diagnostic. Cerebral biopsy of one temporal lobe was performed in 40 cases and a positive diagnosis of acute necrotizing encephalitis was made in 37 of these. Herpes simplex virus was isolated from the brains of 29 of the 40 cases in which the procedure was attempted, but immunofluorescence assays for antigens to herpes simplex virus were only positive in 11 out of 25 cases. Serological assays showed a greater than four-fold rise in the anti-herpes simplex virus antibody litre in 13 out of 22 patients tested.<p></p> A total of 19 patients (41 per cent) survived and 27 (59 per cent) died and the mean survival time from the onset of symptoms to death was 23 days. Both the level of consciousness and the degree of speech deficit on admission were related to eventual outcome, but the age of the individuals did not have as great an effect on the outcome as found in previous studies. Antiviral treatment was given in 27 patients. Eight of the 15 patients (53 per cent) who had received idoxuridine survived and two of these made a useful recovery. Three out of the five (60 per cent) of the patients treated with vidarabine survived and two had a useful outcome. Of the seven cases treated with acyclovir five (71 per cent) survived, three of whom had a useful outcome. Only three (16 per cent) of the 19 patients who did not receive any antiviral treatment survived. Only five individuals were able to return to work and most survivors were left with permanent neurological and/or psychological impairment. The policy widely adopted in the United Kingdom for treating suspected cases of herpes simplex encephalitis empirically with acyclovir now seems justified, but it is critical that such patients be treated early in the disease before either coma or mutism develops.<p></p>

• Item Type: Articles
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Kennedy, Professor Peter
• Authors: Kennedy, P. G. E.
• College/School: College of Medical Veterinary and Life Sciences > School of Infection & Immunity
• Journal Name: QJM: An International Journal of Medicine
• Publisher: Oxford University Press
• ISSN: 1460-2725
• ISSN (Online): 1460-2393