A 39‐year‐old female was referred to our emergency center with a consciousness disorder that got worse by the hour after hospitalization at her local hospital for a urinary tract infection 5 days prior. She had no past medical history. Physical examination revealed the following: Glasgow Coma Scale, E2V2M6; blood pressure, 90/70 mm Hg; heart rate, 110 beats/min; respiratory rate, 30 breaths/min; and body temperature, 38.0°C. White blood cell count, lactate dehydrogenase levels, and c‐reactive protein levels were 26,000/μL, 964 U/L, and 4.61 mg/dL, respectively. Only protein levels were elevated to 140 mg/dL in the cerebrospinal fluid. Magnetic resonance imaging revealed abnormal signals in bilateral thalami, which raised the suspicion of acute necrotizing encephalopathy (ANE) (Fig. 1). High‐dose intravenous methylpredonisolone, immunoglobulins, and 500 mg 3 times/day acyclovir were administered. Herpes simplex virus (HSV)‐specific antibodies were detected in the blood later. Despite intensive care, she succumbed to brain death 14 days after admission. ANE, which has a characteristic multifocal, symmetric, bilateral involvement of the thalami, is the fatal complication of pediatric viral infections. 1 , 2 , 3 Macrophage activation and hypercytokinemia was considered to be in the pathogenesis of ANE. Influenza virus commonly causes adult ANE, making this the first report of HSV‐induced ANE. 3 , 4 , 5
Fig. 1.
Magnetic resonance imaging (MRI) shows bilateral symmetrical thalamic involvement. These lesions demonstrate hypointense on T1‐weighted image (WI), and hyperintense on T2WI and fluid attenuated inversion recovery sequence. Diffusion‐weighted imaging demonstrate diffusion restriction in thalami, and axial apparent diffusion coefficient (ADC) images show trilaminar appearance.
FUNDING INFORMATION
No funding information provided.
DISCLOSURE
Approval of Research Protocol: Not applicable.
Registry and the Registration No. of the Study/Trial: Not applicable.
Informed Consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Conflict of Interest: All authors declare that they have no conflict of interest and the manuscript has not been previously published; the manuscript is not under consideration for publication elsewhere.
ACKNOWLEDGMENTS
The authors thank Enago (www.enago.jp) for the English language review.
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