A rare case of meningoencephalitis with herpes simplex type 1 (HSV-1) with secondary Streptococcus pneumoniae infection

• Published in: Clinical medicine (London, England) Vol. 24; p. 100114
• Main Author: LIN, KO KO
• Format: Journal Article
• Language: English
• Published: Elsevier Ltd 01.04.2024
• ISSN: 1470-2118
• DOI: 10.1016/j.clinme.2024.100114

Meningoencephalitis is a condition in which both the layer of the covering of brain (meninges)and the parenchyma of the brain become inflamed and infected. If only the meninges is involved it is called meningitis and the latter encephalitis but meningoencephalitis is extremely rare condition. 1 The estimated annual incidence of viral meningitis was 2.73 per 100,000 and bacterial meningitis was 1.24 per 100,000. The estimate number of cases of meningoencephalitis cases were expected to be lower than this. The clinical features include fever, neck stiffness, photophobia, seizure, unconsciousness. An elderly gentleman in his early 80s was brought in by ambulance to one of South Wales district general hospital regarding reduced consciousness. He went out with his family the night before and had dinner with family. He threw up around midnight and unable to wake up in morning. PMH- hypertension, Good functional baseline, keen cyclist (did 15 miles every week) His GCS initial assessment by paramedics were low (E2 V2 M3) and found to have low grade fever (38.3 °C). His GCS was still low and unchanged from assessment with paramedics. He did not have any rashes and his capillary blood glucose was 7.6 . A routine set of blood and CXR, ECG and CT () were arranged. All imaging were unremarkable and routine blood test showed very mildly elevated inflammatory markers although his venous blood gas showed normal pH with raised lactate of five and hence CT (abdomen with contrast) was arranged to rule out intra-abdominal pathology. Empirical treatment with IV Tazocin was started but there was no improvement after 24 h. Then, suspicion of CNS infection was raised, and lumbar puncture was done though it was delayed to obtain due to difficulty. The lumbar puncture result was as follow. Macroscopically it looked purulent and urgent discussion with infectious disease were done who suggested to change antibiotics to IV Ceftriaxone and IV acyclovir to treat as meningoencephalitis. Interestingly, the patient developed oral ulcer in the lips (presumed cold sore) which might be primary herpes simplex infection. His lumbar puncture result was RBC × 3, WCC 200 (primarily lymphocytes and polymorph), Herpes Simplex Type 1 PCR positive and Streptococcus pneumoniae positive in CSF culture. His CSF glucose were low and protein high 4 g/L. He had significant improvement on D4 of IV antibiotics and antiviral, GCS improved to 15/15 and his lumbar puncture was repeated after 2 weeks of treatment. His MRI head was unremarkable. Repeat LP result, RBC two, WCC five, Viral PCR negative and no bacterial growth, Normal CSF protein and glucose. The patient was able to walk with Zimmer frame and physiotherapy started in 2-week time and discharge on day 16 of admission. Meningoencephalitis is a serious condition which need timely diagnosis, treatment with appropriate antibiotics and antiviral to prevent mortality and morbidity.