A previously healthy 41-year-old (gravida 4, para 3) woman at 26 weeks of gestation was admitted as an emergency to our tertiary medical hospital city at the High dependency unit. She presented following a first altered mental status. She had a preceding 4-day history of fever and sever headache associated with photophobia ,photophobia and neck pain but no stiffness. Past history included oral herpes, the most recent eruption being some months previously. At presentation, there were no oral or genital tract lesions. There was no recent travel or head injury.
At presentation to the local teaching hospital she was apyrexial, had a GCS of 15/15, and normal cardio-respiratory and neurological examinations. No signs of preeclampsia were detected; She was not hypertensive and urinalysis did not demonstrate proteinuria only leukocytosis with no nitrites ,notably platelet count, serum electrolytes, Her full blood count , renal, liver were normal, the erythrocyte sedimentation rate was 39 (reference range 5–15) mm/hr and C-reactive protein was 6 (<10) mg/L. Computed tomography (CT) showed maxillary and frontal sinuses. Preliminary CSF analysis showed elevated WBC( predominately lymphocytes), protein and normal glucose. CFS panel results revealed a positive polymerase chain reaction (PCR) for herpes simplex virus 1 (HSV-1). CFS culture showed bacillus species isolated from enrichment most likely a contamination. IgG serology results for HSV-1 (1800 IU/mL, normal range <100) and serum HSV-1 PCR were slightly increased. In the ED she received moxifloxzcin , TMP-SMX , vancomycin and dexamthason. On admission meropenems and acyclovir started empirically. Afterward meropeneme have stopped and acyclovir continued for 2? weeks. An electroencephalogram (EEG) showed periodic lateral epileptiform discharge they are not epileptic in nature they are more likely structural. Therefore, Magnetic resonance imaging (MRI) was done and it showed Diffusely thickened oedematose cortices involving the left temporal lobe, limbic system, sylvian cortex and postero medial left subfrontal lobe. Mild diffusion restriction of involved cortices. Ipsilateral lentiform nucleus is spared. During patient hospitalization she a had 1 episode of upper limb jerky movements with some facial twitching and up rolling of the eyes with post-Ictal status ( drooling, up rolling , poor responsiveness ) last for 2 minutes. Load with keppra 2g was commenced and following 500 mg BID IV for seizure prevention in pregnant women. revealed a viable fetus, with no evidence of retroplacental hematoma. A normal fetal heart activity and a normal amniotic fluid volume .Cardiotocography (CTG) was done BID and were normal throughout. First dating scan and NT was done in private clinic was within normal limit as well as the detailed anomaly fetal scan . After monitoring keppra level was 9.7 mg/I patient continued to received keppra 1g BID. Patient was on VTE prophylaxis clexane . electroencephalogram (EEG) was repeated and showed left lateral epileptiform discharge with focal slowing. As per the neurology to increase the dose of keppra to 1500mg . On day 16 patient had anatomical 3rd trimester scan showed Single intrauterine pregnancy seen
Fetal measurements are commensurate with dates. Estimated fetal weight today: 1200 g (+/-15%). This is within normal percentile for gestational age. Normal amniotic fluid volume.
Baby in cephalic presentation. Gender male. Anatomical evaluation performed,
no gross fetal malformations seen. Normal fetal Dopplers. Reassuring cerebral placental ratio of around 2. electroencephalogram (EEG) was repeated for third time and showed left lateral epileptiform discharge with no focal slowing. Magnetic resonance imaging (MRI) was repeated on the day 16 it showed reduction of the oedematose changes and diffusion restriction is involving the left temporal lobe, left insula, left posterior medial frontal lobe, posterior aspect of the left thalamus as well as the medial aspect of the left anterior occipital region
No evidence of dura sinus thrombosis. Patient was discharge with no lp done . Disharge with keppra. Followed by antenatal clinic reaching 32+1 day of gestation patient is alert and oriented but still very forgetful and not able to identify people and places by names .
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