Ictal vomiting as an unusual presentation of herpes simplex encephalitis ‐ Pathophysiological and therapeutic perspectives

Introduction

Herpes Simplex Encephalitis (HSE) is a formidable neurological infection that is often challenging to diagnose owing to its diverse clinical manifestations. This case report details the clinical odyssey of a sixty-year-old female with diabetes, hypothyroidism, and hypertension, who presented with fever, vomiting, and evolving neurological symptoms.

Case Presentation

The patient's initial admission failed to yield a diagnosis, and her condition worsened, marked by behavioral changes, cognitive decline, and focal seizures. Neuroimaging revealed characteristic findings, confirming non-hemorrhagic herpetic encephalitis. Despite antiviral and antiepileptic therapy, persistent vomiting prompted further investigations, uncovering infrequent right temporal sharp waves on EEG, leading to a diagnosis of "ictus emiticus."

Conclusion

This case of Herpes Simplex Encephalitis (HSE) underscores the diverse clinical spectrum and challenges in management. The patient's atypical presentation underscores the importance of considering HSE in patients with fever and unexplained persistent vomiting for early diagnosis and better prognosis.

Diagnostic tools (neuroimaging, cerebrospinal fluid analysis, and electroencephalography) confirmed HSE involvement in the right temporal lobe, emphasizing the strong association between HSV encephalitis and seizures, which can be explained by various mechanisms.

Timely antiviral therapy and tailored antiepileptic strategies led to gradual clinical improvement, showcasing the potential of valproate beyond antiepileptic use.

This case prompts further exploration into HSE's pathophysiology and treatment. It emphasizes individualized patient care and vigilance for potential post-resolution sequelae, contributing to our evolving understanding of HSE.