Objective:

NA

Background:

HSV-2 meningoencephalitis infection has a poor prognosis with the potential for long term disability and death. It is reported in fewer than 2% of all HSV associated CNS infections. HSV-2 meningoencephalitis most commonly occurs in the neonatal period and is only rarely reported in elderly patients with compromised immune function. Early diagnosis and initiation of specific antiviral therapy could potentially improve survival and reduce disability. Here we report a case of ustekinumab associated HSV-2 associated meningoencephalitis in an adult with pan ulcerative colitis with unusual imaging findings and clinical presentation.

Design/Methods:

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Results:

A 52 year old female with severe  ulcerative colitis on ustekinumab 90 mg subcutaneous maintenance presented to us with progressive confusion and global aphasia. She had clinical deterioration with increasing stupor and became unresponsive. A MRI brain demonstrated bilateral, symmetric diffusion restriction and T2 hyperintensity in the thalami, upper cerebral peduncles, and the posterior limb of the internal capsule. Cerebrospinal fluid studies showed hypoglycorrhachia of 4, elevated protein 110, and 127 wbc’s. PCR testing was positive for HSV-2 and negative for other viral and fungal etiologies. She was subsequently treated with 21 days of IV acyclovir and followed by valacyclovir suppression. Follow up MRI brain on day 10 showed interval resolution of thalami and cerebral peduncle findings. At the three month follow up, her cognitive and physical abilities improved, but aphasia persisted.

Conclusions:

HSV-2 meningoencephalitis has no typical imaging findings. Few case reports showed a multifocal stroke pattern on brain MRI. Here we report a first case of HSV-2 associated meningoencephalitis with bilateral thalamic and cerebral peduncle diffusion restriction with stroke like presentation with subsequent resolution of the MRI findings on repeat imaging following specific antiviral therapy.