Re: Herpetic Infections & Neurological Involvement

Posted By CCF Neuro[P] MD, RPS on December 21, 1998 at 08:28:51:

In Reply to: Herpetic Infections & Neurological Involvement posted by Dr. Michael Durant on December 21, 1998 at 01:15:57:






A few weeks ago I posted to this forum for help in the form of another medical opinion.  I am an M.D. but not a neurologist, and I have had a difficult case to resolve in a 33 y/o pt.  I am writing here to the forum to educate any physician who cares to learn about this difficult diagnosis.
My patient is now resolving after bein placed on Valtrex 500mg/3x/day.  He is not immunocompromised, nor were any vesicles ever present during his illness.  What led me to place him on Valtrex was a consultation with an ID physician who told me three things about this case.
1)  My pt. had symptoms affecting the right side of this head, neck, face.  Herpetic infections manifest symptoms that are hemispheric in nature.
2)  Myth:  No immunocompetent individual can have a herpetic meningitis or encephalitis.  FACT:  Many people who are immunocompetent have CNS infections caused by herpetic infections.
3)  Myth:  A herpetic infection will cause visible vesicles on the body, typically the trunk when the CNS is involved.  FACT:  When the CNS is involved, vesicles from a herpetic infection will not necessarily be present on the body.
My suggestion is that the medical community wake up on these three misconceptions.  I made the mistake of overlooking infections that were of the herpes family based on these misconceptions.  It cost my patient nearly six months of his life.  If you care to review my patient's case history, see my post earlier this month (December 8th or 9th?) entitled Dr. In Need Of Assistance With Difficult Diagnosis.  Thank you for the use of your forum, and thank you to those who responded to my previous post.
Dr. Michael Durant
Dear Dr. Durant:
Thanks for the interesting case.  Sometimes it takes so long to answer questions on the forum, we apologize (I should apologize for myself) for the delay.  A questions, although there was evidence for a "cold or canker sore" and neurological signs and symptoms, 1) The MRI with contrast did not show any meningeal enhancement? 2) the CSF did not show any lymphocytosis?  My next question is whether a PCR was ever performed and did it show type I or type II HSV or another HSV?  Thanks again.
Sincerely,
CCF Neuro[P] MD, RPS