Insights into adjunctive corticosteroid therapy in fulminant herpes simplex virus encephalitis: case analysis with contrasting outcomes

Abstract

Herpes simplex virus (HSV) encephalitis, predominantly caused by HSV-1, presents with significant morbidity and mortality challenges. This research investigates the particular role of adjunctive corticosteroid therapy in fulminant HSV encephalitis through in-depth analyses of two contrasting cases. Corticosteroids show potential benefits to improve an exaggerated immune response and limit viral dissemination within the brain. Daily assessments and frequent neuroimaging, particularly using magnetic resonance imaging, aid in the management of fulminant cases. Although existing evidence relies on limited case series and retrospective comparisons, the results of the present study emphasize the necessity for large-scale controlled trials to establish definitive guidelines. The discretion of the treating neurologist governs the decision to implement corticosteroids, emphasizing the imperative need for continued research and evidence-based strategies for this challenging neurological condition.

Keywords: Encephalitis; Steroids; Herpes simplex virus.

Figure 1.. Brain MRI findings

Brain MRI showing T2/fluid-attenuated inversion recovery hyperintensity with restricted diffusion in the left temporal, left insular, left pulvinar, left cortical parietal, bilateral cingulate (left predominant), bilateral basifrontal (left predominant), and right posterior mesial temporal areas, accompanied by minimal rightward midline shift measuring up to 0.3 cm. MRI, magnetic resonance imaging.

Figure 2.. Brain MRI findings

Brain MRI showing the extension of lesions to the right occipitoparietal lobes, presenting diffuse underlying leukomalacia with delineation of multifocal hemorrhagic areas, predominantly located in the left temporal lobe. MRI, magnetic resonance imaging.

Figure 3.. MRI findings of hyperintense lesions and diffusion restriction

Brain MRI exhibiting hyperintense lesions on T2-weighted images, with notable diffusion restriction observed in the inferior frontal lobes and medial temporal lobes bilaterally. MRI, magnetic resonance imaging.

Figure 4.. CT scan findings of brain

CT scan of the brain showing global loss of gray-white matter differentiation with hyperdensity of hemorrhagic components in the left frontoparietal regions with near complete effacement of the ventricular system and extra-axial CSF cisterns with features indicative of tonsillar herniation. CT, computed tomography.