Journal of the Formosan Medical Association (2015) 114, 1295e1296
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
CORRESPONDENCE
Glioblastoma masquerading as herpes simplex encephalitis Jianwen Wang, Benyan Luo* Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Received 30 April 2014; received in revised form 19 July 2014; accepted 29 July 2014
A 50-year-old man presented with headache, confusion, and an episode of seizure. Two days prior to admission the patient complained of headache without nausea, vomiting, or fever. The day prior to admission his temperament changed, he was easily irritated and seemed to have hallucinations or illusions. He was sometimes in a confused state and experienced a 60-second seizure spell on the day of admission. There was no remarkable family or personal history. On admission, the patient’s vital signs were normal but he was confused and could not answer questions or follow verbal commands. The motor examination revealed withdrawal of all extremities from noxious stimuli. Reflexes were 2þ throughout, and the plantar responses were flexor. Signs for meningitis signs were negative. An emergent computerized tomography (CT) scan of the head showed a hypodense region in the left frontaleparietal lobe. Lumbar puncture revealed the cerebral spinal fluid (CSF) pressure was 200 mmH2O. Examination of the CSF showed white blood cells of1/mL, protein levels of 0.68 g/L and glucose levels of 3.4 mmol/L. Herpes simplex virus immunoglobulin G antibody in the CSF was positive. A brain magnetic resonance imaging (MRI) obtained on the 2nd day showed high T2 signal change affecting the left temporal and parietal lobes and left thalamus. There were also scattered high T2 signal change in both semioval centers and an abnormal lesion in the Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, No. 79, Qingchun Road, Hangzhou, 310003, China. E-mail address: [email protected] (B. Luo).
left frontaleparietal lobe consistent with widened VirchoweRobin space (Fig. 1). An electroencephalography was abnormal showing nonspecific diffuse slowing. Routine laboratory studies including blood routine tests, live and renal function, blood sugar, thyroid function, antinuclear antibody, erythrocyte sedimentation rate, C-reactive protein, alphafetoprotein, carcinoembryonic antigen, were all unremarkable. The patient was treated with acyclovir and methylprednisolone under the suspicion of herpes simplex encephalitis (HSE). Two weeks later, his symptoms mostly resolved with mild memory and cognitive impairment. A repeated brain MRI with gadolinium enhancement showed the lesion in the left temporal and parietal lobes was slightly resolved (Fig. 1). The patient was discharged home. Two months later, the results of a third brain MRI scan remained unchanged. Four and a half months later, the patient was admitted with dizziness and underwent a fourth brain MRI scan. The MRI revealed an increase in the size of the left temporal and parietal lesion on T2-weighted image. Two new heterogeneous contrast-enhancing lesions were shown on gadolinium-enhanced T1 weighted images (Fig. 1). The patient underwent a surgical resection of the left parietal lesion. The diagnosis of glioblastoma was confirmed on histopathologic findings. Glioblastoma is a diffusely growing malignant brain neoplasm with characteristic histological features, and a few cases of glioblastoma can present as acute encephalitic syndrome or encephalopathy. Whitley et al1 confirmed that two out of 95 patients who were biopsy-negative for HSE had glioblastoma. Rees and Howard2 reported three cases of high grade glioma which mimicked acute viral encephalitis. Nam et al3 reported another case with glioblastoma mimicked
http://dx.doi.org/10.1016/j.jfma.2014.07.012 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
1296
J. Wang, B. Luo
Figure 1 (AD). Initial brain MRI showed high T2 signal change affecting the left temporal and parietal lobes and left thalamus, and scattered high T2 signal change in both semioval center. The abnormal lesion in the left frontaleparietal lobe was consistent with widened VirchoweRobin space. (EeH) Brain MRI obtained 2 weeks later showed the lesions in the left temporal and parietal lobes were slightly resolved. (IeL) Brain MRI obtained 4.5 months later showed an increase in the size of the left temporal and especially the left parietal lesion on T2-weighted image. (MeP) Gadolinium-enhanced T1 weighted image showed two new heterogeneous contrast-enhancing lesions in the left parietal and temporal lobe. MRI Z magnetic resonance imaging.
HSE and corticosteroid-induced temporal improvement. There was one interesting case with the occurrence of HSE and glioblastoma.4 In patients with indefinite diagnosis of HSE, brain MRI follow-up is needed to document the evolution of the brain lesion and stereotactic brain biopsy is necessary to confirm the pathologic diagnosis.
References 1. Whitley RJ, Cobbs CG, Alford Jr CA, Soong SJ, Hirsch MS, Connor JD, et al. Diseases that mimic herpes simplex
encephalitis. Diagnosis, presentation, and outcome. JAMA 1989; 262:234e9. 2. Rees JH, Howard RS. High-grade glioma mimicking acute viral encephalitise-three case reports. Postgrad Med J 1999;75: 727e30. 3. Nam TS, Choi KH, Kim MK, Cho KH. Glioblastoma mimicking herpes simplex encephalitis. J Korean Neurosurg Soc 2011;50: 119e22. 4. Lins H, Kanakis D, Heinrichs T, Dietzmann K, Wallesch CW, Mawrin C. Sudden progression of a glioblastoma in partial remission? Clin Neurol Neurosurg 2004;106:335e6.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
CORRESPONDENCE
Glioblastoma masquerading as herpes simplex encephalitis Jianwen Wang, Benyan Luo* Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China Received 30 April 2014; received in revised form 19 July 2014; accepted 29 July 2014
A 50-year-old man presented with headache, confusion, and an episode of seizure. Two days prior to admission the patient complained of headache without nausea, vomiting, or fever. The day prior to admission his temperament changed, he was easily irritated and seemed to have hallucinations or illusions. He was sometimes in a confused state and experienced a 60-second seizure spell on the day of admission. There was no remarkable family or personal history. On admission, the patient’s vital signs were normal but he was confused and could not answer questions or follow verbal commands. The motor examination revealed withdrawal of all extremities from noxious stimuli. Reflexes were 2þ throughout, and the plantar responses were flexor. Signs for meningitis signs were negative. An emergent computerized tomography (CT) scan of the head showed a hypodense region in the left frontaleparietal lobe. Lumbar puncture revealed the cerebral spinal fluid (CSF) pressure was 200 mmH2O. Examination of the CSF showed white blood cells of1/mL, protein levels of 0.68 g/L and glucose levels of 3.4 mmol/L. Herpes simplex virus immunoglobulin G antibody in the CSF was positive. A brain magnetic resonance imaging (MRI) obtained on the 2nd day showed high T2 signal change affecting the left temporal and parietal lobes and left thalamus. There were also scattered high T2 signal change in both semioval centers and an abnormal lesion in the Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, No. 79, Qingchun Road, Hangzhou, 310003, China. E-mail address: [email protected] (B. Luo).
left frontaleparietal lobe consistent with widened VirchoweRobin space (Fig. 1). An electroencephalography was abnormal showing nonspecific diffuse slowing. Routine laboratory studies including blood routine tests, live and renal function, blood sugar, thyroid function, antinuclear antibody, erythrocyte sedimentation rate, C-reactive protein, alphafetoprotein, carcinoembryonic antigen, were all unremarkable. The patient was treated with acyclovir and methylprednisolone under the suspicion of herpes simplex encephalitis (HSE). Two weeks later, his symptoms mostly resolved with mild memory and cognitive impairment. A repeated brain MRI with gadolinium enhancement showed the lesion in the left temporal and parietal lobes was slightly resolved (Fig. 1). The patient was discharged home. Two months later, the results of a third brain MRI scan remained unchanged. Four and a half months later, the patient was admitted with dizziness and underwent a fourth brain MRI scan. The MRI revealed an increase in the size of the left temporal and parietal lesion on T2-weighted image. Two new heterogeneous contrast-enhancing lesions were shown on gadolinium-enhanced T1 weighted images (Fig. 1). The patient underwent a surgical resection of the left parietal lesion. The diagnosis of glioblastoma was confirmed on histopathologic findings. Glioblastoma is a diffusely growing malignant brain neoplasm with characteristic histological features, and a few cases of glioblastoma can present as acute encephalitic syndrome or encephalopathy. Whitley et al1 confirmed that two out of 95 patients who were biopsy-negative for HSE had glioblastoma. Rees and Howard2 reported three cases of high grade glioma which mimicked acute viral encephalitis. Nam et al3 reported another case with glioblastoma mimicked
http://dx.doi.org/10.1016/j.jfma.2014.07.012 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
1296
J. Wang, B. Luo
Figure 1 (AD). Initial brain MRI showed high T2 signal change affecting the left temporal and parietal lobes and left thalamus, and scattered high T2 signal change in both semioval center. The abnormal lesion in the left frontaleparietal lobe was consistent with widened VirchoweRobin space. (EeH) Brain MRI obtained 2 weeks later showed the lesions in the left temporal and parietal lobes were slightly resolved. (IeL) Brain MRI obtained 4.5 months later showed an increase in the size of the left temporal and especially the left parietal lesion on T2-weighted image. (MeP) Gadolinium-enhanced T1 weighted image showed two new heterogeneous contrast-enhancing lesions in the left parietal and temporal lobe. MRI Z magnetic resonance imaging.
HSE and corticosteroid-induced temporal improvement. There was one interesting case with the occurrence of HSE and glioblastoma.4 In patients with indefinite diagnosis of HSE, brain MRI follow-up is needed to document the evolution of the brain lesion and stereotactic brain biopsy is necessary to confirm the pathologic diagnosis.
References 1. Whitley RJ, Cobbs CG, Alford Jr CA, Soong SJ, Hirsch MS, Connor JD, et al. Diseases that mimic herpes simplex
encephalitis. Diagnosis, presentation, and outcome. JAMA 1989; 262:234e9. 2. Rees JH, Howard RS. High-grade glioma mimicking acute viral encephalitise-three case reports. Postgrad Med J 1999;75: 727e30. 3. Nam TS, Choi KH, Kim MK, Cho KH. Glioblastoma mimicking herpes simplex encephalitis. J Korean Neurosurg Soc 2011;50: 119e22. 4. Lins H, Kanakis D, Heinrichs T, Dietzmann K, Wallesch CW, Mawrin C. Sudden progression of a glioblastoma in partial remission? Clin Neurol Neurosurg 2004;106:335e6.
