Pediatr Radiol (1992) 22:145
Pediatric Radiology 9 Springer-Verlag 1992
Involvement of the white matter in the initial stage of herpes simplex encephalitis T. Ichiyama, T. Hayashi, E. Yamaguchi, H. Tanaka, and K. Hagiwara Department of Pediatrics, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan 755 Received: 3 September 1991; accepted: 2December 1991
Magnetic resonance imaging (MRI) is the most sensitive procedure in early diagnosis of herpes simplex encephalitis (HSE) [1-3]. The previous reports of M R I findings in H S E were of predominantly gray matter involvement in the early stage of the illness. We describe a girl with H S E who had striking changes in the white matter on M R I in the acute stage.
Case report A 1-year-old girl was admitted to our University Hospital with a history of fever, vomiting, left-sided hemiconvulsion, gait disturbance, and drowsiness. The cerebrospinal fluid (CSF) on the 9th day of illness revealed 157 white blood cells/mm 3 (68 % monocytes), 64 mg/dl of protein, 59 mg/dl of glucose, and 4.2 ng/ml ( < 4.0 ng/ml) of myelin basic protein. Herpes simplex virus (HSV) DNA was detected in the CSF on the 9th day by the use
of polymerase chain reaction method [4]. A high Ig M titer against to HSV type I was also detected in the CSE Periodic slow and sharp wave discharges were recorded in the right fronto-temporal region on the electroencephalogram. Intravenous acyclovir was given atadoseofl0 mg/kg8 hourly for 10 days.The T2-weighted MRI on the 15th day showed increased signal intensities in the white matter of the right temporal lobe (Fig. 1 a). No HSV DNA was detected in the CSF on day 23. The patient's symptoms had resolved by day 37. T2-weighted MRI follow-up on day 71 revealed widespread involvement of the right temporal lobe (Fig. 1 b). MRI on day 92 demonstrated no progression of the lesions. A mild left hemiparesis was still present when she was discharged on day 109.
M R I findings has not yet been reported in HSE, and differs from earlier reports [1-3]. It is possible that the lesions are due to an infiltration of inflammatory cells and/or demyelination, consistent with parainfectious encephalitis, as the increased signal intensities in the right temporal lobe on T2-weighted M R I were located in the white matter. The pathological picture of a perivenous inflammatory demyelination was has been reported in H S E [5].
Acknowledgement. We thank Dr. Hiroshi Kimura, Department of Pediatrics, Nagoya University School of Medicine for performing the HSV DNA detection of the CSF by polymerase chain reaction method.
Discussion The M R I findings of our patient were characterized by prominent lesions in the white matter in the early stage. This
Fig.1. a T2-weighted MRI, 1.5-Tesla axial view (spin-echo, TR = 3.000 ms; TE = 90 ms) on day 15 shows increased signal intensities in the white matter of the right temporal lobe. b T2weighted MRI on day 71 shows widespread increased signal intensities in the gray and white matter of the right temporal lobe
References 1. Schroth G, Gawehn J, Thron A, Vallbracht A, Voigt K (1987) Early diagnosis of herpes simplex encephalitis by MRI. Neurology 37:179 2. Neils EW, Lukin R, Tomsick TA, Tew JM (1987) Magnetic resonance imaging and computerized tomography scanning of herpes simplex encephalitis. J Neurosurg 67:592 3. Schroth G, Kretzschmar K, Gawehn J, Voigt K (1987) Advantage of magnetic resonance imaging in the diagnosis of cerebral infections. Neuroradiology 29:120 4. Rowley AH, Whitley R J, Lakeman FD, Wolinsky SM (1990) Rapid detection of herpes-simplex-virus DNA in cerebrospinal fluid of patients with herpes simplex encephalitis. Lancet 335:440 5. Koenig H, Rabinowitz SG, Day E, Miller V (1979) Postinfectious encephalomyelitis after successful treatment of herpes simplex encephalitis with adenine arabinoside. N Engl J Med 300:1089
T. Ichiyama, MD Department of Pediatrics Yamaguchi University School of Medicine Ube, Yamaguchi Japan 755
Pediatric Radiology 9 Springer-Verlag 1992
Involvement of the white matter in the initial stage of herpes simplex encephalitis T. Ichiyama, T. Hayashi, E. Yamaguchi, H. Tanaka, and K. Hagiwara Department of Pediatrics, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan 755 Received: 3 September 1991; accepted: 2December 1991
Magnetic resonance imaging (MRI) is the most sensitive procedure in early diagnosis of herpes simplex encephalitis (HSE) [1-3]. The previous reports of M R I findings in H S E were of predominantly gray matter involvement in the early stage of the illness. We describe a girl with H S E who had striking changes in the white matter on M R I in the acute stage.
Case report A 1-year-old girl was admitted to our University Hospital with a history of fever, vomiting, left-sided hemiconvulsion, gait disturbance, and drowsiness. The cerebrospinal fluid (CSF) on the 9th day of illness revealed 157 white blood cells/mm 3 (68 % monocytes), 64 mg/dl of protein, 59 mg/dl of glucose, and 4.2 ng/ml ( < 4.0 ng/ml) of myelin basic protein. Herpes simplex virus (HSV) DNA was detected in the CSF on the 9th day by the use
of polymerase chain reaction method [4]. A high Ig M titer against to HSV type I was also detected in the CSE Periodic slow and sharp wave discharges were recorded in the right fronto-temporal region on the electroencephalogram. Intravenous acyclovir was given atadoseofl0 mg/kg8 hourly for 10 days.The T2-weighted MRI on the 15th day showed increased signal intensities in the white matter of the right temporal lobe (Fig. 1 a). No HSV DNA was detected in the CSF on day 23. The patient's symptoms had resolved by day 37. T2-weighted MRI follow-up on day 71 revealed widespread involvement of the right temporal lobe (Fig. 1 b). MRI on day 92 demonstrated no progression of the lesions. A mild left hemiparesis was still present when she was discharged on day 109.
M R I findings has not yet been reported in HSE, and differs from earlier reports [1-3]. It is possible that the lesions are due to an infiltration of inflammatory cells and/or demyelination, consistent with parainfectious encephalitis, as the increased signal intensities in the right temporal lobe on T2-weighted M R I were located in the white matter. The pathological picture of a perivenous inflammatory demyelination was has been reported in H S E [5].
Acknowledgement. We thank Dr. Hiroshi Kimura, Department of Pediatrics, Nagoya University School of Medicine for performing the HSV DNA detection of the CSF by polymerase chain reaction method.
Discussion The M R I findings of our patient were characterized by prominent lesions in the white matter in the early stage. This
Fig.1. a T2-weighted MRI, 1.5-Tesla axial view (spin-echo, TR = 3.000 ms; TE = 90 ms) on day 15 shows increased signal intensities in the white matter of the right temporal lobe. b T2weighted MRI on day 71 shows widespread increased signal intensities in the gray and white matter of the right temporal lobe
References 1. Schroth G, Gawehn J, Thron A, Vallbracht A, Voigt K (1987) Early diagnosis of herpes simplex encephalitis by MRI. Neurology 37:179 2. Neils EW, Lukin R, Tomsick TA, Tew JM (1987) Magnetic resonance imaging and computerized tomography scanning of herpes simplex encephalitis. J Neurosurg 67:592 3. Schroth G, Kretzschmar K, Gawehn J, Voigt K (1987) Advantage of magnetic resonance imaging in the diagnosis of cerebral infections. Neuroradiology 29:120 4. Rowley AH, Whitley R J, Lakeman FD, Wolinsky SM (1990) Rapid detection of herpes-simplex-virus DNA in cerebrospinal fluid of patients with herpes simplex encephalitis. Lancet 335:440 5. Koenig H, Rabinowitz SG, Day E, Miller V (1979) Postinfectious encephalomyelitis after successful treatment of herpes simplex encephalitis with adenine arabinoside. N Engl J Med 300:1089
T. Ichiyama, MD Department of Pediatrics Yamaguchi University School of Medicine Ube, Yamaguchi Japan 755
