Objective:

To present an atypical presentation of herpes simplex virus (HSV) encephalomyelitis. 

Background:

Immunocompromised adults are susceptible to HSV-2 reactivation which is significantly less common than HSV-1 and with more varied clinical and radiographic presentations. Early recognition and treatment is crucial as there is an upwards of 70% mortality rate without treatment. 

Design/Methods:

Not applicable

Results:

A 39-year-old female with a history notable for uveitis on immunosuppressive therapy, migraine with aura, and ovarian cysts presented with generalized body aches, worsening headaches different from her migraines, gait instability with multiple falls, right-sided paresthesia including her trunk, urinary retention, constipation, and saddle anesthesia. A computed tomography angiogram of her head and neck revealed an acute intraparenchymal 9-millimeter left medullary hematoma. Magnetic resonance imaging (MRI) of her brain and spinal cord revealed focal T2 hyperintense lesions in the right cingulate gyrus and T6-T7 central cord suggesting inflammation or demyelination. A lumbar puncture was performed which resulted in lymphocytic pleocytosis with elevated protein and polymerase chain reaction positive for HSV-2. Intravenous acyclovir was initiated for 21-days. At follow-up, MRI revealed an underlying medullary cavernoma and interval resolution of brain and spinal cord T2 hyperintensities. Clinically, the patient had mildly dysarthric speech, the paresthesias were improved but still present, and her cauda equina symptoms resolved. 

Conclusions:

Clinicians should be aware of uncommon HSV presentations given its high mortality rate and consider it as part of a broad differential, especially for immunocompromised patients. In this specific case, we present an immunocompromised young woman with underlying cavernoma that hemorrhaged likely due to HSV-induced vasculopathy and Elsberg syndrome: a rare cause of cauda equina syndrome secondary to lumbosacral radiculoneuritis.