Encephalitis Associated with Acute Hepatitis A
A 27-year-old man visited our hospital because of a sudden-onset generalized convulsion. He had been overworking and had slept less than 5 hours a day for the previous month. A week prior to the hospital visit, the patient had developed a fever and generalized myalgia but had not taken any medicine. High fever, anorexia, and generalized malaise appeared. On the day of the hospital visit, he could not be awakened, and he showed no responses to any stimulus. Finally, he developed a generalized tonic-clonic seizure that lasted for about three min and that was accompanied by cyanosis, upward eyeball deviation, and tongue biting.\nOn physical examination at the emergency department, the patient’s body temperature rose up to 38.7°C. He did not show jaundice, hepatosplenomegaly, nor ascites. He was confused and could not follow the examiner’s verbal commands appropriately, and he often attempted to run out of the bed while yelling incomprehensible words and abuses. Neck stiffness was found on neurologic examination. Positive or negative myoclonic jerk was not observed.\nBrain computed tomography and magnetic resonance imaging showed no abnormalities. Diffuse slowing without epileptiform discharges was observed on electroencephalography (EEG) recordings. The cerebrospinal fluid (CSF) was clear, and its pressure was measured at 16.0 cmH2O, with 20 leukocytes/μL (95% lymphocytes), protein levels of 70.5 mg/dL, and normal glucose levels (63.0 mg/dL). Blood tests showed that white blood cell counts were increased to 17,230 cells/μL. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and γ-glutamyl transpeptidase levels were increased to 441, 1294, and 460 IU/L, respectively. Total bilirubin and direct bilirubin levels were normal (0.6 mg/dL and 0.2 mg/dL, respectively). Creatine phosphokinase levels were elevated up to 14,500 IU/L. Serum ammonia levels were normal (24 μg/dL).\nSeizure did not relapse after 30 min of continuous infusion of 15 mg/kg of phenytoin mixed with normal saline. He regained consciousness on the second admission day and became fully conscious the following day. Intravenous acyclovir was given for two days because of the clinical suspicion of herpes encephalitis, which was discontinued after observing the clinical improvement and the detection of the IgM antibody of HAV. The patient’s score on the Korean version of the mini-Mental Status examination (K-MMSE) score was 30 on the fifth admission day. Serum and CSF IgM antibodies of herpes simplex type 1, 2, and varicella zoster were negative. Polymerase chain reaction (PCR) of the CSF for HAV and enterovirus were also negative. AST and ALT levels decreased to 125 and 432 IU/L on the seventh admission day. He was discharged without any sequela. During the year after discharge, he had been seizure-free with normal EEG recordings.