Abstracts

Rationale: HSV-1 is a common cause of sporadic encephalitis in the United States. HSV encephalitis is typically associated with fever, alteration of consciousness, behavioral disturbances and seizures. Alteration in intrinsic excitability of hippocampal neurons plays a critical role in the generation of seizures. Hippocampal pyramidal cells influx calcium during the action potential, which activate a number of potassium channels, which then contribute to repolarization and further seizures and behavioral changes. NMDA glutamate also plays a role in epileptogenesis. Enhancement of hippocampal pyramidal cell excitability, neuronal loss and mossy fiber sprouting may result in overall vulnerability to generate epileptiform activity. Status epilepticus is rare. Recurrent nonconvulsive status epilepticus is extremely rare and has not been reported in the literature. We present an unusual patient of HSV-1 encephalitis who presented with recurrent status epilepticus. Methods: This is retrospective evaluation of a patient who was admitted to the St. Joseph's Regional Medical Center. Results: Our patient is a 22 y/o old Hispanic female who presented with seizure and low-grade fever during her last trimester of pregnancy. Subsequently she had emergency cesarean section (CS) for her delivery. She had no signs or symptoms of pre-eclampsia or eclampsia. Soon after her CS she had multiple seizures for which she had CSF evaluation. Her CSF showed lymphocytosis and elevation of proteins. Her initial CSF was negative for HSV PCR antibody. Her brain biopsy was confirmatory for encephalitis, showing perivascular cuffing and inflammatory cells. Her subsequent CSF was confirmatory for HSV PCR encephalitis. During her hospitalization, she had prolonged EEG monitoring for several days. Her EEG showed right temporal evolving periodic rhythmic electrographic discharges which were initially refractory to phenytoin. She was subsequently treated with levitiracetam in conjunction with phenytoin, and her seizures were under control. Her MRI findings were suggestive of increasing gyriform enhancement in the right temporal and occipital lobes, anterior medulla, pons, and mid brain, with a minimal area of enhancement within the right superior cerebellum. There was a diffuse increase in signal within the sulci with enhancement compatible with encephalitis. She was discharged, in stable condition. She was readmitted again with seizures, double vision and headache. After EEG and MRI evaluation, she was treated with foscarnet, anti epileptic medications and eventually was discharged. She represents a rare case of HSV encephalitis with recurrent nonconvulsive status epilepticus. Conclusions: Seizures are common in HSV encephalitis. It may present with status epilepticus as an initial manifestation. However recurrent nonconvulsive status epilepticus is quite uncommon presentation. Prompt neurophysiologic monitoring may be helpful to identify potential life threatening status epilepticus and further consequences.