17 1 Issue 2 lume oV 2011 Current Neurobiolog Current Neurobiology 2011; 2 (1): 17-22 Devastating Outcomes Following Herpetic Encephalitis Tamer Rizk and Yasser Awaad Pediatric Neurology Department, KFMC, Riyadh, Saudi Arabia Abstract Neurological complications following herpetic encephalitis are not uncommon, though dev- astating neurological deficits are uncommon complications of herpetic encephalitis. We de- scribe 4 cases who presented with herpetic encephalitis that, despite receiving early therapy, passed through a progressive devastating course. We discuss the risk factors that may pre- dispose patients to these complications and how to avoid their progression. There are no clear data regarding the incidence of herpetic encephalitis in Saudi Arabia. It seems that the incidence is increasing with the emergence of post meningoencephalitic se- quelae that need long term follow up and rehabilitation measures. We aim to raise a red flag for better management of herpetic encephalitis in a way to avoid devastating post herpetic encephalitis. Key words: Herpes Simplex, encephalitis, outcomes. Accepted February 23 2011 Introduction Herpes simplex virus (HSV) infections of the central nervous system (CNS) are the most common cause of sporadic encephalitis, with an incidence of more than 2,000 cases annually in the United States. (1) An additional 1,500 cases occur as disseminated neonatal herpes sim- plex encephalitis, caused by HSV type 2, bringing the total burden of the serious disease to more than 3,500 cases per year. (2) Furthermore, atypical, and less severe cases of herpes simplex encephalitis bring this number towards a higher rate. (3) Recent data estimated an inci- dence of about 1 in 250,000 to 500,000 people per year and a third of cases occurring in children. (4) Tremendous advances in the ability to diagnose HSV, coupled with the establishment of safe and effective anti- viral therapies, have improved overall outcomes. How- ever, the seriousness of HSV CNS infections requires that clinicians maintain a high index of suspicion to initiate evaluation and treatment under suitable circumstances. Intravenous Acyclovir remains the mainstay of antiviral management (5) , which decreases mortality dramatically from 75% to 25 %. ( 1, 6 & 7) A dramatic improvement of the survival rate and progno- sis occurs if treatment is initiated very early after the on- set of the disease. Early diagnosis is, therefore, crucial for predicting the outcome. (8) Polymerase Chain Reaction (PCR) detection of HSV DNA is considered the gold standard to confirm HSV encephalitis with an estimated sensitivity of 96% and specificity of 99% for early diagnosis. Reports with false negative PCR results, with sensitivity reaching only 70%– 75%.This fact could be related to the absence of HSV or the presence of a very low viral load in the CSF at the onset of an acute encephalitic process in children, may be due to the presence of heme and other inhibitors If given early in the clinical course of HSE. (9) Acyclovir reduces both mortality and morbidity in treated patients. It should be administered at a dosage of 20mg/kg every 8 hours (60mg/kg/d) for a period of 21 days. Proper and immediate treatment of HSV encephalitis has proven to decrease neurological impairments in survivors, with many patients reporting minor or no neurological impair- ment at follow-up. (10) Case I A two year and 6 months old boy presented with on and off fever; reaching 39-40 degrees Celsius; for one week followed by progressive decreased level of consciousness for one day. He was healthy until the age of 2 years and 5 months, when he suffered from high grade fever, vomit- ing, and attacks of generalized tonic clonic seizures. He