Steroids for Deteriorating Herpes Simplex Virus Encephalitis Banan Musallam, MD*, Israel Matoth, MD*, Dana G. Wolf, MD † , Dan Engelhard, MD*, and Diana Averbuch, MD* A 16-month-old girl presented with herpes simplex virus type 1 encephalitis with involvement of bilateral parietofrontal lobes, left thalamus and cerebellum. She was treated with intravenous acyclovir. As her condi- tion deteriorated, high-dose methylprednisolone was administered, resulting in remarkable improvement. This case suggests considering a short course of high- dose steroid therapy in severe herpes simplex enceph- alitis when there is clinical and radiologic deterioration in spite of appropriate antiviral therapy and decreas- ing viral load in the cerebrospinal fluid. © 2007 by Elsevier Inc. All rights reserved. Musallam B, Matoth I, Wolf DG, Engelhard D, Averbuch D. Steroids for deteriorating herpes simplex virus encephalitis. Pediatr Neurol 2007;37:229-232. Introduction Herpes simplex virus encephalitis is a severe disease, often leading to permanent neurologic damage [1,2]. It is the most common cause of fatal sporadic encephalitis in the United States. It strikes all age groups, with 10% of cases occurring in children 6 months to 10 years of age [1]. The clinical syndrome includes rapid onset of fever, headache, seizures, focal neurologic signs, and impaired consciousness [2]. Treatment with antiviral agents does not always result in complete recovery [3]. Steroids are not included in the routine therapeutic regimen because of concern that their immunosuppressive activity may in- crease viral replication and spread [4,5]. The present case is that of a 16-month-old girl with herpes simplex virus type 1 encephalitis who developed further neurologic deterioration several days after initia- tion of acyclovir treatment and improved dramatically after addition of corticosteroids to her treatment regimen. The pros and cons for steroid treatment in herpes enceph- alitis are discussed. Case Report A 16-month-old girl, previously healthy, was admitted to the Pediatric Department at the Hadassah University Hospital, Jerusalem, with fever up to 40°C, irritability, and refusal to move her right arm. Her past history was unremarkable, and her development was appropriate for her age. Physical examination revealed an extremely irritable child, who later became lethargic, with fever of 40°C. Meningeal signs were suspected, but difficult to assess due to poor cooperation. There were no signs of trauma. Neurologic examination revealed paresis of the right hand, without other findings including papilledema. A lumbar puncture showed 57 polymorphonuclear cells/mm 3 and 8 lymphocytes/mm 3 with normal cerebrospinal fluid biochemistry. Treatment with intravenous ceftriaxone 100 mg/kg per day and acyclovir 1500 mg/m 2 per day was initiated. Shortly after admission, the patient had a focal seizure of her right upper extremity, for which she was treated with phenobarbital 20 mg/kg loading dose, followed by 5 mg/kg per day. A cranial computed tomographic scan revealed high-density foci surrounded by vasogenic edema in the upper part of the left parietal lobe, compatible with hemorrhage, inflammation, or both. Electroencephalography revealed slow and high-voltage waves in the left hemisphere. Magnetic resonance imaging revealed focal edema in the bilateral parietofrontal lobes (Fig 1), cerebellum (Fig 2), and left thalamus (data not shown). The diagnosis of herpes simplex virus type 1 encephalitis was documented by positive herpes simplex virus type 1 polymerase chain reaction in the cerebrospinal fluid with viral load, performed by real-time polymerase chain reaction, 11,000 copies/mL. The bacterial blood and cerebrospinal fluid cultures were negative, and ceftriaxone was discon- tinued. The clinical course of the child did not change significantly during the first 8 days. She had continuous fever of 38.6-39.4°C, but was less lethargic and started to move her right arm. On the 9th day of acyclovir therapy, however, the patient deteriorated. She became more lethargic and aphasic, her right hand hemiparesis worsened, and right leg hemi- paresis was noticed. Repeat magnetic resonance imaging revealed en- largement of the edematous foci, central hemorrhage, and mild pressure on the midline (Fig 3). Repeat lumbar puncture revealed the same lymphocyte count, 5 polymorphonuclear cells/mm 3 , and a decrease in the herpes simplex viral load in the cerebrospinal fluid, to 750 copies/mL. Oligoclonal antibodies were negative in the cerebrospinal fluid. Because of the clinical deterioration in the face of a decreasing viral load, it was From *Department of Pediatrics and † Clinical Virology Unit, Hadassah University Hospital, Ein Kerem, Jerusalem, Israel. Communications should be addressed to: Dr. Averbuch; Pediatric Infectious Diseases; Department of Pediatrics; Hadassah University Hospital; POB 12000; IL-91120 Jerusalem; Israel. E-mail: dina8282@walla.co.il Received January 31, 2007; accepted May 16, 2007. 229 © 2007 by Elsevier Inc. All rights reserved. Musallam et al.: Steroids in Herpes Encephalitis doi:10.1016/j.pediatrneurol.2007.05.007 ● 0887-8994/07/$—see front matter