LAUSR

Herpes simplex encephalitis (HSE) is a rare neurological condition (~2–4 per million) marked by brain inflammation caused by herpes simplex virus (HSV). HSE is associated with both cognitive and neuropsychiatric symptoms, particularly memory and executive dysfunction. We present the case of a 63-year-old, right-handed, St. Lucian female who completed serial neuropsychological evaluations (NPE). The patient presented with a six-day history (per collateral) of fever, confusion, and nausea. The patient denied cognitive changes. Magnetic Resonance Imaging (MRI) revealed leptomeningeal enhancement in the right sylvian fissure, multiple right temporal sulci, and inferior right frontal lobe (Figure 1). There was no indication of seizures. Cerebrospinal fluid analysis was positive for HSV-1. A two-week course of intravenous acyclovir was initiated on hospital day three. (Table 1). Initial NPE results (day five) revealed global cognitive impairment with sparing of auditory attention; exam was limited secondary to significant fatigue. Following completion of antivirals, subsequent NPE (day 17) revealed similar findings, despite improved alertness; left neglect (Figure 2) and significant anosagnosia (i.e., lack of disease awareness) and anosodiaphoria (i.e., indifference reaction to neurological deficits) were noted. Two-month outpatient follow-up NPE revealed marginal improvement in aspects of language and learning, but continued memory impairment, dense anosagnosia, and anosodiaphoria. In this case, the patient presented with salient neuropsychiatric sequelae of HSE that have not been commonly associated with this condition in the extant literature. Her denial of cognitive symptoms may have initially confounded the differential diagnosis, emphasizing the importance of multi-specialty collaboration. Limitations of available normative data also complicated examination.