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admin 23.01.2016

Gross atrophy of the right temporal lobe (grey and white matter) with ex-vacuo dilatation of the right temporal horn.  Surrounding T2 brightening indicative of gliosis.
Herpes simplex encephalitis is a devastating infection and if not treated early can cause severe destruction of brain tissue leading to gross atrophy as evidenced by this case. Herpes simplex encephalitis (HSE) is the most common sporadic focal encephalitis produced by Herpes simplex virus type I. HSE manifests with classical features of acute focal encephalitis and rarely may have a chronic smouldering course. Herpes virus is a DNA virus and 7 viruses of Herpes viridae family have been isolated from humans: HSV1, HSV2, Varicella zoster, Epstein Barr virus (EBV), Cytomegalo virus (CMV), Human herpes virus 6 and 7.

The patients with classic HSE manifest with fever, behavioural abnormality, personality change, focal seizure and aphasia.
If the PCR is negative and patients come in the second week, CSF lgM antibody against HSV is also diagnostic.
In neonatal and immune-compromised HSE patients, double the adult dose of acyclovir is given for 21 days. The most important predictors of outcome are delayed treatment, depth of coma and extremes of age. In immune-competent adults, 90% of HSE is due to HSV1 and the remaining 10% are due to HSV2.

After the availability of PCR, milder patients with HSE have been recognized with focal or diffuse encephalitis without severe alteration in sensorium and they recover well. MRI finding of frontotemporal involvement is suggestive of HSE in a patient with acute febrile encephalopathy (Fig 1). HSV1 encephalitis has a bimodal distribution- one-third cases occur before 20 years and half the cases after 50 years of age.

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