Critical Care: Fellow Case Report Poster - Critical Care I |

Anaplastic Astrocytoma Presenting as Herpes Simplex Encephalitis FREE TO VIEW

Prarthna Chandar, MBBS; Sakthidev Kulandaisamy, MD; Yizhak Kupfer, MD; Chanaka Seneviratne, MD; William Pascal, MD; Srirupa Hari Gopal, MBBS
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Maimonides Medical Center, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):231A. doi:10.1016/j.chest.2016.08.244
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SESSION TITLE: Fellow Case Report Poster - Critical Care I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Infections are the most common cause of acute encephalitis.CNS malignancies are rare cause of acute encephalitis;We report a case of an anaplastic astrocytoma that presented with signs and symptoms mimicking herpes encephalitis(HSE).To our knowledge only two other cases have been reported(1).

CASE PRESENTATION: A 77 year old male presented to the emergency department with one week history of fever, worsening headache, behavioral changes, and paresthesias progressing to seizures.On admission he was febrile,with normal cognition and mild weakness of the left arm and leg. Neuroimaging revealed grey-white distinction loss and sulcal effacement involving the right and mesial temporal lobes with extensive edema, midline shift and uncal herniation consistent with HSE.A lumbar puncture was not attempted,in view of high risk of herniation.An EEG showed periodic,epileptiform discharges in the temporal lobe,a common finding in HSE.Despite treatment with intravenous acyclovir, dexamethasone and phenytoin, his encephalopathy worsened.Repeat neuroimaging revealed worsening intracerebral edema and extension of the previously noted temporal lesion.The patient was treated with mannitol with some clinical improvement and transferred to a neurocritical ICU.A lumbar puncture done under close neurological monitoring there was negative for Herpes Simplex.A stereotactic brain biopsy revealed a high grade anaplastic astrocytoma.He was deemed not a surgical candidate and was offered palliative chemo and radiotherapy.

DISCUSSION: The treatment of acute encephalitis depends on its cause.CNS malignancies rarely present as an acute encephalitis.Anaplastic astrocytoma is a WHO grade III astrocytoma usually presenting in the fourth decade.It is a tumor of the glial cells with extensive atypia.On imaging it appears with an increased attenuation pattern lacking the vascular proliferation and hemorrhagic necrosis pattern of glioblastoma.The average survival after diagnosis is 3-5 years.Definitive treatment involves surgical resection followed by chemotherapy with temozolide and radiotherapy.However recurrences after surgery are common.

CONCLUSIONS: Anaplastic astrocytoma usually presents in the fourth decade but can present in the elderly and can mimic HSE.Patient's empirically treated for herpes simplex encephalitis who don’t respond appropriately should undergo further testing including brain biopsy.

Reference #1: J H Rees, R S Howard Postgrad Med J1999; ‘High-grade glioma mimicking acute viral encephalitis75:727-730 doi:10.1136/pgmj.75.890.727

DISCLOSURE: The following authors have nothing to disclose: Prarthna Chandar, Sakthidev Kulandaisamy, Yizhak Kupfer, Chanaka Seneviratne, William Pascal, Srirupa Hari Gopal

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