Investigations

CT scan shows low attenuation in the inferior frontal and--

temporal lobes but may be normal in early stages. MRI is abnormal at an earlier stage, showing bilateral temporal lobe and limbic involvement, often with haemorrhagic change.

CSF examination reveals 5-500 lymphocytes. The protein is mildly elevated and the glucose is normal. IgG is elevated and oligoclonal bands are present.

EEG examination shows generalised slowing with bursts of 'periodic' high voltage slow wave complexes over the involved temporal lobe.

Virus specific antibodies appear in serum and CSF. HSV-DNA is detected in CSF by Polymerase Chain reaction (PCR), a new technique for rapid early diagnosis. Brain biopsy seldom required in view of the above newer diagnostic techniques.

This shows evidence of a necrotising encephalitis with intranuclear eosinophilic inclusion bodies.

Demonstrate herpes simplex antigen by immunofluorescence.

Differential diagnosis

Consider:

- other forms of encephalitis

- cerebral abscess

- brain tumour.

Isolate virus by culture (positive in 48 hours). Treatment

Acyclovir inhibits DNA synthesis; 30 mg/kg/day is given in divided dosage (to avoid renal toxicity) for 10-14 days.

This treatment has reduced mortality from 70% to 20% with a similar reduction in neurological sequelae (memory disturbance, etc.).

Since acyclovir is relatively non-toxic, treatment should be commenced on suspicion of disease. Delay will adversely affect outcome.

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