Abstract Details

Title HSV-2 Encephalitis Presenting with Immune-Responsive Chorea

Topic Autoimmune Neurology

Presentation(s) P12 - Poster Session 12 (5:30 PM-6:30 PM)

Poster/Presentation
Number 9-003

Background Chorea has been associated with late-onset autoimmune encephalitis triggered by HSV-1. These symptoms are linked to but may also be present in the absence of anti-NMDA receptor antibodies. Chorea has yet to be described with HSV-2 encephalitis nor has it been described as a presenting symptom in any HSV infection.

Objective To recognize the presentation of chorea as an immune mediated presenting symptom of HSV-2 encephalitis.

Design/Methods Clinical case description

Results

A 72-year-old woman with type II diabetes presented with mental status and found to be febrile to 101.4F without meningismus. Neurological examination demonstrated impaired attention and choreiform movements. Cerebrospinal fluid (CSF) analysis revealed a pleocytosis of 234 cells/uL with 95% lymphocytic predominance and an elevated protein of 72mg/dL. CSF PCR was positive for herpes simplex virus 2. Oligoclonal bands were present. The remaining CSF workup was negative including an autoimmune encephalitis panel. Contrast MR brain was unremarkable. Despite treatment with acyclovir, there was no notable improvement in mental status or choreiform movements. On hospital day six, the patient was treated with intravenous immunoglobulins (IVIG) for suspected para-infectious autoimmune encephalitis. She was started on plasmapheresis after two sessions of IVIG as she developed hypotension with IVIG. Her chorea was significantly improved after just one session, with complete resolution after the fourth session. She received a total of five sessions of plasmapheresis and three weeks of acyclovir treatment and was noted to be back at her baseline cognitive and functioning status at three months follow-up.

Conclusions This is the first case associating immune-mediated chorea with HSV-2 encephalitis, supporting that concurrent early CNS autoimmunity and active viral infection can occur, even with undetectable autoantibodies and normal neuroimaging. Early diagnosis and treatment with immune therapies along with antivirals are pivotal to optimize the clinical outcome.

Authors/Disclosures
Michael D. Kolesnik, DO (University of Colorado) PRESENTER	Dr. Kolesnik has nothing to disclose.
Ahmad A. Ballout, MD (Hofstra North Shore-LIJ School of Medicine Program)	Dr. Ballout has nothing to disclose.
Natasha Hameed, MD (Northwell Health)	Dr. Hameed has nothing to disclose.
Souhel Najjar, MD (Hofstra University North Shore LIJ School of Medicine Lennox Hill Hospital)	Dr. Najjar has nothing to disclose.