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Herpes simplex encephalitis in patients with malignant glioma

RESUMO

APS, male, 30 years old, began with strabismus and horizontal diplopia, headache, nausea, vomiting ,dizziness, weakness and hypoesthesia in the left side, evolving with difficulty walking, dysphagia, dysarthria three months ago. Neurological exam showed alternating syndrome characterized by a lesion in VI cranial nerve (NC) on the right, complete hemiparesis provided on the left and hemihypoesthesia on the left. MRI evidenced heterogeneous expansive/infiltrative lesion, with hypersignal on T2/FLAIR, focus of contrast uptake in the central portion, diffusely affecting the pons, extending inferiorly to the medulla oblongata and right superior and middle cerebellar peduncles, compression of the fourth ventricle. Considering the diagnosis of Diffuse Midline Glioma, was prescribed Stupp Protocol. One month later, the patient developed fever, brad psychism and tonic-clonic seizures. MRI with punctate cerebellar hemorrhages, thrombocytopenia (92,000), cerebrospinal fluid (CSF) with glucose 48, protein 106, leukocytes 53 (predominance of lymphocytes and monocytes), negative cultures and DNA of Herpes Virus 1 was detected in CSF. After 10 days of Acyclovir intravenously, the patient improved the level of consciousness. Maintained follow-up, used adjuvant with TMZ, however there was tumor growth during the fourth cycle, being currently in palliative care. Discussion: Herpes simplex encephalitis (HSE) is a very severe infection of the central nervous system, affecting immunocompetent in most cases. Perhaps, nowadays, it has been more commonly HSV encephalitis in immune-suppressed patients than is currently recognized. Some studies suggest an increased risk in patients with cancer and indicate that chemotherapy and steroid administration could even induce HSE without brain irradiation by disrupting host immunity², promoting HSV reactivation. Other studies imply some specific vulnerability in use of TMZ upregulates a protein that results in promoting viral replication, cell death and tissue injury1. One of the difficulties to identify HSE condition is moderate symptoms in these patients and a cluster of alternative etiologies, like systemic infection, cancer progression, metabolic diseases. Conclusion: Otherwise the co-occurrence of HSE and glioma is rare and the benefits of TMZ chemoradiation overtake the risks in malignant glioma, HSE can happen during the standard treatment. So, in case of suspicion, the treatment should be promptly started to avoid more damage.

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