Sabeen F Mekan, Mohammad Wasay, Bhojo Khelaeni, Zarrish Saeed, Ali Hassan, Mughis Sheerani.
Herpes Simplex Encephalitis: analysis of 68 cases from a tertiary care hospital in Karachi, Pakistan.
J Pak Med Assoc Jan ;55(4):146-8.

The involvement of allocortical temporal lobe pathways is particularly suggestive of HSE. The incidence of extra temporal involvement in HSE is not well known. To test the hypothesis that extra temporal involvement is common in HSE we conducted this retrospective study of consecutive patients. A retrospective review was performed on the charts of all patients (n=88) who were admitted to the Aga Khan University, Karachi with diagnosis of HSE from 1990-2002. The diagnosis of HSE in these patients was based on the combination of clinical findings, CSF pleocytosis, positive PCR and focal EEG abnormalities. RESULTS: Clinical findings included fever (n=53, 78%), seizures (n=44, 65%), altered mental status (n=37, 54%), aphasia (n=8, 12%) and hemiparesis (n=8, 12%). All patients underwent CSF analysis. CSF was abnormal in 65 (96%) patients while three patients (4%) had normal CSF. Pleocytosis was present in 44 patients (65%). Lymphocytic pleocytosis was present in nearly all of the patients (n=43). The CSF abnormalities also included elevated protein (45 patients) and low glucose (25 patients). Fifteen patients had positive CSF PCR for HSV while three patients had positive IgM antibodies against HSV. Sixty patients had EEG that showed generalized or focal abnormalities in 56 patients (82%). Other EEG abnormalities included focal slowing (n=15), sharp waves (n=8), status epilepticus (n=8) and spikes (n=8). Twenty three patients had normal CT / MRI scans (34%). Temporal lobe involvement was noted in 34 patients (50% of all patients, 76% of those with lesions on neuroimaging). Eleven patients had purely extra temporal lesions with no involvement of the temporal lobes (16% of all patients, 24% of those with lesions on neuroimaging). Treatment of all these patients included Acyclovir 10 mg/kg three times a day for 14 days. Seven patients died despite treatment. Average hospital stay was 11 days (Range 6-33 days). At the time of discharge, seventeen patients showed normal neurological exam, 29 were ambulatory with assistance and 15 were bedridden. CONCLUSION: In conclusion, though highly treatable, HSE is still associated with high morbidity and mortality. Early diagnosis helps in early treatment and prevention of morbidity and mortality. MRI technology is emerging as one of the most sensitive and specific test to diagnose HSE which should not be ruled out in the absence of temporal lobe involvement.

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