Case report

A 46-year-old, previously well, right-handed man presented with a 1 week history of headache, vomiting and confusion. On examination his temperature was 38.3°C, Glasgow Coma Scale score was 14/15 (E4V4M6) and he was severely expressively dysphasic. There was no limb weakness. Initial blood tests, including C reactive protein, were normal. Cranial CT revealed a hypodense area in the left anteromedial temporal lobe (figure 1). Microscopy of CSF from a lumbar puncture showed a pleocytosis (390×10⁶/ml, lymphocytes 95%), with no organism.

On a working diagnosis of herpes simplex virus (HSV) encephalitis, empirical intravenous aciclovir was commenced. PCR of the CSF later confirmed HSV type 1. Subsequent HIV tests were negative. On day 3, MRI showed a recent small haemorrhage (figure 2). On day 6, the patient developed an acute right-sided hemiplegia. Urgent CT revealed a temporal lobe acute haematoma (figure 3). He was …