Pearls & Oy-sters: Cerebral HSV-2 vasculitis presenting as hemorrhagic stroke followed by multifocal ischemia

HSV causes a wide range of pathologies in the human CNS including meningitis, myelitis, and encephalitis (HSE). Even with early initiation of antiviral treatment and advances in neurocritical care, HSE remains a life-threatening condition associated with high mortality and morbidity. Cerebrovascular complications contribute to the devastating prognosis and include brain edema, ischemic stroke, and intracerebral hemorrhage.1 Primary or secondary vasculitis related to an underlying disease may be restricted to the nervous system or involve multiple organs in the context of systemic disease. The list of pathogens that may cause vascular inflammation within the CNS is comprehensive.2 Among herpesviruses, a high frequency of vasculitic complications is reported for varicella zoster virus (VZV).3 Here, we report a case of cerebral HSV-2 vasculitis, which was masked by the initial presentation as thalamic hemorrhage and followed by an encephalitic syndrome and multifocal ischemic stroke. A 72-year-old immunocompetent man was referred with acute onset of nonfluent aphasia and right-sided weakness. CT scan revealed a 4 × 1.8 cm left thalamic hemorrhage. He was taking ramipril and a combination of pioglitazone/metformin due to hypertension and diabetes, respectively. Since he had been living alone, details on prior signs and symptoms were scarce and complicated by aphasia. Laboratory examinations including coagulation parameters …