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Herpes simplex encephalitis (HSE) is frequently complicated by seizures. Immunosuppression is a recognised side effect of anticonvulsant therapy. We present a case of recurrent HSE where host immunocompetence was impaired because of hypogammaglobulinaemia, most likely induced by carbamazepine therapy.
A 40-year-old man presented to his local hospital with a 5 day history of rigors, nausea, vomiting and photophobia. He reported formed visual hallucinations and his wife complained that over the preceding week he had been uncharacteristically short tempered. A tonic–clonic seizure was witnessed in the accident and emergency department. A cranial CT scan was normal. CSF analysis showed 120 white cells/mm3 (lymphocytes 100%), 3 red cells/mm3 and no organisms on gram stain. The CSF opening pressure was 36 cm water and protein concentration 770 mg/l (150–450). He was treated with intravenous cefotaxime, aciclovir (10 mg/kg) and phenytoin, with a presumptive diagnosis of encephalitis. Increased signal in the right medial temporal lobe was noted on an MRI scan. An EEG revealed abnormal excess theta/delta waves over both hemispheres, consistent with diffuse cerebral dysfunction. Dexamethasone (4 mg three times daily) was started on day 2 of admission. Subsequently, herpes simplex virus (HSV) DNA type …