A misleading case of encephalitis in cirrhotic diabetic patient: The importance of early diagnosis

Abstract

We present the case of a 67 year-old cirrothic man, referred to our hospital for disorientation, hyporexia, nausea, vomiting and hyperglycemia. At admission he was pyretic and disoriented, no neurological signs were present and laboratory examination showed mild hyperammonemia with normal inflammatory markers. Chest X-ray demonstrated a probable pneumonia and urinary infection was found, therefore systemic antibiotic therapy was initiated. After one week of antibiotic therapy, despite hyperammonemia resolution, the patient remained pyretic with progressive worsening of his mental state. Head CT scan was performed, demonstrating a large hypodense area in temporal lobe confirmed by brain MRI. Lumbar puncture was immediately performed and CSF PCR revealed HSV1-DNA positivity. Antiviral therapy with acyclovir at dosage of 10 mg/kg daily was initiated and continued for three weeks with complete defervescence, partial improvement of the state of consciousness and negativity of HSV1-DNA on CSF control. Two months later the patient was hospitalized again for urinary sepsis and developed a fatal frontal-parietal-temporal cerebral empyema. In cirrothic encephalopatic patient with persistent hyperpyrexia and normal or slight incremented inflammatory markers, herpetic encephalitis must be suspected even without neurological signs. Diagnosis retardation could be associated with elevated morbidity and mortality.