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Fever and Severe Headache in a Young Man
Published on Patient Care Online (http://www.patientcareonline.com)
Fever and Severe Headache in a Young Man
August 01, 2002 | Headache [1], Infection [2], Oral Medicine [3], Pain [4]
A 28-year-old man presents to the emergency department with high fever; progressive, severe,
generalized, throbbing headache; blurred vision; and increasing confusion. These symptoms started
3 days earlier.
A 28-year-old man presents to the emergency department with high fever; progressive, severe,
generalized, throbbing headache; blurred vision; and increasing confusion. These symptoms started
3 days earlier.
History. The patient had previously been healthy and active; he works in the oil fields. He is married
and does not smoke, drink alcohol, or use illicit drugs. He has had no blood transfusions and takes no
medications.
Examination. This well-built man appears ill. Pulse rate is 110 beats per minute; temperature,
38.3C (101F); respiration rate, 22 breaths per minute; blood pressure, 116/72 mm Hg. He is well
hydrated. No scleral icterus or oral candidal infection. Pupils are equal and reactive. No palpable
adenopathy or rashes. The patient is confused; disoriented to person, time, and place; and agitated.
Cranial nerves are intact. Fundi are normal. He can move all his limbs. Deep tendon reflexes are
normal; plantar reflexes are equivocal. Neck is supple. Remainder of the examination is normal.
Laboratory studies. White blood cell (WBC) count, 18,000/µ L, with 70% polymorphonuclear
neutrophils and 30% lymphocytes. Hemoglobin level is 13.1 g/dL; platelet count, 200,000/µ L;
erythrocyte sedimentation rate, 90 mm/h. Serum sodium level is 138 mEq/L; potassium, 4 mEq/L;
chloride, 102 mEq/L; calcium, 9.2 mg/dL; blood glucose, 101 mg/dL; blood urea nitrogen, 29 mg/dL;
serum creatinine, 1 mg/dL; total bilirubin, 1 mg/dL; aspartate aminotransferase, 22 U/L; alanine
aminotransferase, 26 U/L; alkaline phosphatase, 112 U/L. Results of coccidial serologic testing and
drug screening are negative. Urinalysis results are normal.
Cerebrospinal fluid (CSF) pressure is increased. CSF protein level is 180 mg/dL; glucose, 92 mg/dL;
WBC count, 116/µ L (all lymphocytes); red blood cell count, 80/µ L. Gram staining of CSF shows
WBCs but no organisms.
You order an MRI scan of the brain.
What abnormalities are evident here—and to what diagnosis does the clinical picture
point?
A. Viral meningitis
B. Acute multiple sclerosis
C. Multifocal leukoencephalopathy
D. CNS lymphoma
E. Herpes encephalitis
WHAT'S WRONG: The MRI scan shows low-density lesions in the brain, which represent areas of
gross demyelination (Figure). In a patient with fever, severe headache, and altered mental status
who has an abnormal level of lymphocytes in the CSF, these MRI findings strongly suggest herpes
encephalitis, E.
Hospital course. The patient is promptly admitted, and acyclovir, 500 mg IV q8h, is started.
Nasogastric feeding is initiated; a percutaneous gastric tube is later inserted.
Polymerase chain reaction (PCR) testing of the CSF reveals herpes simplex virus (HSV). A VDRL test
and tests for coccidioidal antibodies and oligobands are negative. An electroencephalogram (EEG)
shows spike and slow wave activity with a temporal predominance.
Outcome. After 2 weeks, the patient's fever and headache resolve. Unfortunately, he is still
disoriented and has difficulty in remembering and recognizing people. He is transferred to a
rehabilitation hospital for further treatment; a maintenance regimen of acyclovir, 400 mg bid, is
prescribed.
A CASE IN POINT HSV encephalitis accounts for approximately 10% of all cases of encephalitis in
the United States. About 2000 cases of HSV encephalitis occur each year, and up to 70% of patients
die. The majority of those who survive have serious neurologic sequelae.
Herpes encephalitis occurs throughout the year and affects patients of all ages. It is most commonly
caused by HSV-1; HSV-2 can cause neonatal encephalitis, in which the virus is acquired from the
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Fever and Severe Headache in a Young Man
Published on Patient Care Online (http://www.patientcareonline.com)
mother.
Clinical features. The illness evolves over several days. Symptoms include fever, headache, acute
alteration of mental status (for example, confusion, stupor, or coma), seizures, and focal neurologic
findings, such as aphasia or hemiplegia.
CSF tests. The CSF pressure is often increased. Examination of the fluid almost invariably shows
pleocytosis (up to 500/µ L, mainly lymphocytes). Red blood cells are found in some patients; this
finding reflects the hemorrhagic nature of the CNS lesions. The protein level is increased in most
patients. The CSF glucose level may be normal or decreased; tuberculosis and fungal meningitis are
also associated with a decreased glucose level, which can create confusion.
The PCR technique has revolutionized the diagnosis of HSV encephalitis. The sensitivity of this test is
95% at the time of presentation; the specificity is nearly 100%. Viral cultures may be obtained from
the CSF and HSV antibody may be detected 8 to 12 days after the onset of the disease.
Other diagnostic studies. CT scanning of the brain demonstrates low-density lesions with
nonenhancing areas and surrounding edema in about 70% of patients a few days after the onset of
symptoms. MRI can reveal frontobasal and temporal lesions earlier than CT and is the imaging
method of choice for HSV encephalitis.
EEG changes usually consist of periodic high-voltage sharp waves in the temporal regions and slow
wave complexes at regular 2 to 3 per second intervals. These findings are suggestive of, but not
specific for, the disease.
Brain biopsy and viral cultures, which are rarely done today, definitively establish the diagnosis.
Typical CSF findings that are confirmed by the results of PCR and MRI studies are now accepted for
the diagnosis of HSV encephalitis.
Treatment. The management of HSV encephalitis includes aggressive supportive measures, such
as maintenance of fluid-electrolyte balance and nutritional and respiratory support. Specific therapy
consists of IV acyclovir, 30 mg/kg/d for 14 days; however, such therapy has not been proved in
randomized, controlled trials to reduce morbidity and mortality.
Prognosis. The patient's age and state of consciousness at the time acyclovir is initiated govern
both mortality and morbidity. If patient is unconscious, the outcome is uniformly poor. If treatment is
begun within 4 days of the onset of illness in a conscious patient, survival is increased to
92%—although two thirds of those who survive will be neurologically impaired. Untreated HSV
encephalitis is rapidly progressive, and mortality approaches 70%.
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[1] http://www.patientcareonline.com/headache
[2] http://www.patientcareonline.com/infection
[3] http://www.patientcareonline.com/oral-medicine
[4] http://www.patientcareonline.com/pain
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