Management of suspected herpes simplex virus encephalitis in adults in a UK teaching hospital

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					■ ORIGINAL PAPERS                                                                           Clinical Medicine 2009, Vol 9, No 3: 231–5

Management of suspected herpes simplex virus encephalitis
in adults in a UK teaching hospital

David J Bell, Ruth Suckling, Michael M Rothburn, Tom Blanchard, David Stoeter, Benedict Michael,
Richard PD Cooke, Rachel Kneen and Tom Solomon

ABSTRACT – The outcome of herpes simplex virus (HSV)                    Introduction
encephalitis is improved with prompt initiation of aciclovir
treatment. Delays are common, but there is little under-                Herpes simplex virus (HSV) encephalitis is a rare but serious neu-
standing of why they occur. The case notes of 21 adults                 rological infection with an estimated annual incidence of 1 in
admitted with suspected HSV encephalitis over one year                  250,000 to 500,000.1 The classic presentation of HSV encephalitis
were reviewed. The median (range) duration of illness was               is of a fever, headache, altered consciousness, focal neurological
2.5 (1–99) days. Seventeen (81%) patients had a lumbar                  signs and seizures.2,3 Intravenous aciclovir is an effective treat-
puncture (LP) performed, at a median (range) time of 24                 ment, reducing mortality and morbidity.4,5 Several publications
(2–114) hours after encephalitis was suspected. Lumbar                  have shown that delays in initiating treatment are associated with
puncture was delayed for a computed tomography (CT) scan                a worse prognosis,2,6 however, there has been little work to under-
in 15 patients, but only one of these had contraindications             stand why the delays occur. To better understand the processes
to an immediate LP. The median (range) time from presenta-              involved in managing such patients the case notes of adults with
tion to starting aciclovir was 48 (2–432) hours. HSV-PCR                suspected HSV encephalitis admitted to a teaching hospital in the
(polymerase chain reaction) was requested on cerebrospinal              UK over a 12-month period were retrospectively reviewed.
fluid from 12 patients, one of whom was positive. Five
(24%) patients were given the wrong dose of aciclovir.                  Methods
Overall the management of suspected HSV encephalitis was
often sub-optimal, with delays in LP occurring due to unnec-            The study was conducted at University Hospital Aintree, a large
essary CT scans, and the wrong aciclovir dose administered.             teaching hospital in Liverpool serving a population of approxi-
Guidelines for the management of suspected encephalitis                 mately 330,000 with around 88,000 attendances to the accident
are needed.                                                             and emergency (A&E) department each year. Two methods were
                                                                        used to identify patients with suspected encephalitis admitted
KEY WORDS: aciclovir, central nervous system infection,                 between June 2003 and May 2004. The electronic hospital phar-
encephalitis, herpes simplex virus, lumbar puncture                     macy records were searched for prescriptions of intravenous (iv)
                                                                        aciclovir, and patients who received aciclovir for oral or genital
                                                                        herpetic lesions or for treatment of varicella zoster virus skin
                                                                        infections were subsequently excluded. In addition, the microbi-
1David   J Bell, Specialist Registrar; 2,6Ruth Suckling, Specialist     ology electronic records were searched for requests for HSV-
Registrar; 3Michael M Rothburn, Consultant Medical Microbiologist       PCR (polymerase chain reaction) on cerebrospinal fluid (CSF),
and Infection Control Doctor; 4Tom Blanchard, Consultant in             or for ‘encephalitis’ in the clinical information. Data were col-
Infectious Diseases and Tropical Medicine; 6David Stoeter, Specialist   lected from the hospital notes on the presenting history and
Trainee; 2,6Benedict Michael, Academic Clinical Fellow; 3Richard PD
                                                                        clinical features, the dates and times of medical review and rele-
Cooke, Consultant Medical Microbiologist; 5,6Rachel Kneen,
                                                                        vant investigations, the treatments given and the final diagnosis
Consultant Paediatric Neurologist; 2,6Tom Solomon, Professor of
Neurology and Medical Research Council Senior Clinical Fellow           made. The study was registered with the hospital audit depart-
                                                                        ment and all data were handled according to national guidance.
1Tropical and Infectious Diseases Unit, Royal Liverpool University
Hospital, Liverpool; 2Division of Neurology, Walton Centre for
Neurology and Neurosurgery, Liverpool; 3Department of Clinical          Results
Microbiology, University Hospital Aintree NHS Trust, Liverpool;
4Department for Infectious Diseases, North Manchester General           In total, 29 patients were identified who had been prescribed iv
Hospital, Manchester; 5The Roald Dahl EEG Unit, R
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