Pitfalls associated with the diagnosis of herpes simplex encephalitis
An 84-year-old woman was found on the floor with altered mental status and myoclonic jerks. Some days earlier, levofloxacin was prescribed by her physician due to cystitis. On admission, the patient was somnolent and disorientated, but without meningeal irritation. On both arms, myoclonic jerks could be observed. The working diagnosis in the emergency room was quinolone associated delirium. In order to exclude other etiologies, a CCT was performed, revealing a hypodense lesion in the right temporal lobe []. The following CSF analysis showed elevated lymphocytic cell count (36/μL; normal < 4) and protein (961 mg/dl (normal < 450)); lactate and glucose were normal []. A therapy with acyclovir (10 mg/kg every 8 h for 14 days) was initiated. PCR assay for HSV-1 was found to be positive. Gradually the patient recovered and took part in a rehabilitation program. A year later, the patient was admitted due to a symptomatic seizure. At this time, she still showed marked neurocognitive impairment, needing moderate home care.