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A 32-year-old male with a past medical history of genital herpes and a 1 week history of headaches, presented with nausea, vomiting and diarrhoea, and had a generalised tonic–clonic seizure. His temperature was 38.1°C and CSF laboratory values were: 14 white blood cells (WBC) (100% monocytes), 16 red blood cells, protein 498 mg/dl and glucose 86 mg/dl; serum WBC 12.7 with 75% neutrophils (polymorphonuclear leucocytes). T1 weighted MRI with gadolinium revealed patchy enhancement of the meninges (figure 1A). Serum herpes simplex virus IgG was positive. Viral, herpes simplex virus and bacterial CSF cultures were negative. Acyclovir was started empirically. Two weeks later he suddenly became unresponsive. MRI revealed worsening meningea/temporal lobe enhancement and hydrocephalus (figure 1B). Serum WBC was …
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.