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Correspondence to Dr Amos Lal, [email protected], [email protected]
Background
Cerebral venous sinus thrombosis (CVST) is an uncommon cause of venous stroke due to conditions such as infections, trauma, surgery, drugs, thrombophilic disorders and cancers.1–3 CVST is less common than other types of strokes and could be more challenging to diagnose due to its varying presentation. Thrombosis of the intracranial venous drainage system produces array of symptoms. Intracranial infection can trigger a cascade of biochemical changes that can alter patient’s clinical condition. These biochemical changes may also lead to concurrent development of complications that can modify the clinical progression. Herpes simplex virus (HSV) encephalitis is not an uncommon intracranial infection, with acyclovir being the treatment of choice.4 Viral encephalitis is found to be the most common cause of encephalitis in large case series.5 6 The general outcome for the patient with timely and appropriate treatment is promising. Early initiation of acyclovir increases chances of promising recovery and extent of brain parenchyma involvement on the MRI has a prognostic value.7 We report a rare presentation of HSV encephalitis complicated by CVST in a patient with no other risk factors.
Case presentation
A 31-year-old man was brought to the hospital after his first ever episode of a generalised tonic-clonic seizure. Other symptoms were 3 days of fever, generalised headache and photophobia. He did not have a history of seizure, drug abuse, alcohol or other significant illness. He had no pertinent medical history and was not on any long-term medications. He was a lifelong non-smoker with no family history of seizures, cancers or thrombophilias. Neurological examination revealed mild drowsiness and neck rigidity. Initial CT of the brain and laboratory tests showed no abnormality, including a normal white cell count. Cerebrospinal fluid (CSF) analysis showed a lymphocyte predominant pleocytosis, with normal glucose and protein. Gram stain did not show any organisms, but a CSF PCR was positive for HSV. He was treated for acute meningoencephalitis with intravenous acyclovir. He became more alert, and the headache resolved gradually. However, on day 6, the patient developed bilateral upper limb weakness, incoordination and worsening headache. An urgent MRI brain showed changes in the...