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Central JSM Neurosurgery and Spine

Case Report *Corresponding author

Libby Kosnik Infinger, 96 Jonathan Lucas St. Suite 301

HSV-2 Meningitis Presenting CSB, Charleston, South Carolina 29425, USA, Tel: 843-
697-5056; Fax: 873-792-9279; Email:

with Acute Hydrocephalus

Submitted: 27 November 2013
Accepted: 12 January 2014
Published: 16 January 2014

Ultimately Requiring Long Term Copyright

2014 Infinger et al.


Libby Kosnik Infinger* and Abhay K. Varma Hydrocephalus
Department of Neurosciences, Division of Neurosurgery, Medical University of South Meningitis
Carolina, USA Herpes simplex virus
Aqueductal stenosis
Ventriculoperitoneal shunt

Herpes simplex virus type 1 and 2 can infect the human nervous system causing meningitis and encephalitis. HSV meningitis tends to be benign, but HSF
encephalitis can have a high morbidity and mortality despite treatment. We present a case of HSV meningitis leading to hydrocephalus without evidence of
encephalitis. The patient had persistent hydrocephalus requiring long term CSF diversion despite successful treatment of the infection.
A 57 year old African-American female presented with acute decline in sensorium secondary to hydrocephalus. HSV type 2 was isolated from the CSF
by polymerase chain reaction (PCR). There was no evidence of infiltrative lesion in the brain parenchyma on MRI. She was treated with CSF diversion and
antiviral therapy. The meningitis was successfully treated, but the patient required ventriculoperitoneal shunt placement due to persistent hydrocephalus. This is
the second reported case of post HSV-2 meningitis presenting with acute hydrocephalus, and first reported case of persistent hydrocephalus following HSV-2
Adult HSV-2 meningitis usually has a benign course. Hydrocephalus is rare sequelae of this condition. The patient in this case was treated for HSV meningitis,
and the virus was cleared from the CSF upon repeat PCR testing. Aqueductal stenosis from ependymal inflammation may play a role in the pathophysiology of
hydrocephalus. This is the first reported case of persistent hydrocephalus following HSV-2 meningitis that required a permanent CSF diversionary procedure.
Viral etiology should be actively sought in a case of spontaneous and unexplained hydrocephalus, even in an adult.

successful treatment of the infection. Ependymal inflammation
HSV: Herpes Simplex Virus; PCR: polymerase chain reaction;
with aqueductal narrowing may be the cause of hydrocephalus.
CSF: Cerebral Spinal Fluid; VPS: Ventricular Peritoneal Shunt
A 57 year old African American woman presented to an
Herpes simplex Virus (HSV) type 1 and type 2 can infect outside hospital with a three day history of lethargy, decreased
the human nervous system. HSV is the commonest cause of oral intake, and decreased speaking. She was treated for
sporadic encephalitis [1]. HSV can also cause meningitis, myelitis dehydration and released. When her symptoms persisted she
and radiculitis [2]. HSV encephalitis carries a grave prognosis. returned to the same facility and a computerized tomogram (CT)
Mortality reaches 70% in untreated patients and can be as revealed acute hydrocephalus (Figure 1). She was transferred
high as 30% in treated patients with a high incidence of severe to our facility for neurosurgical care. She had a history of
neurological deficit in survivors [2]. The clinical course of HSV ovarian cancer at age 18 and was also successfully treated for
meningitis tends to be benign. HSV associated aseptic meningitis lymphoma in the past per her family. On examination she had
occurs often after primary HSV-2 genital infection [3]. HSV-1 is a GCS of 10. Fundoscopic exam revealed bilateral papilledema.
more commonly associated with encephalitis [4]. We present An external ventricular drain (EVD) was placed revealing an
a case of HSV-2 meningitis leading to hydrocephalus without opening pressure of 52 cm of H2O. Initial CSF analysis revealed:
evidence of intracranial lesion. This is the second case reported RBC 213cumm, WBC 52cumm, Neutrophils 11%, Lymphocytes
in the literature of post HSV-2 meningitis presenting with acute 80%, Glucose 73 mg/dl, Protein 42 mg/dl, Gram stain was
hydrocephalus. In the first case, the patient was not treated with negative for bacteria. HSV polymerase chain reaction (PCR) was
anitvirals, and did not require long-term CSF diversion [16]. Our positive for HSV-2. Her mental status improved after placement
case is unique in that the patient had persistent hydrocephalus of the EVD and GCS was then 13. Contrast enhanced magnetic
requiring ventricular peritoneal shunt placement despite resonance imaging (MRI) after EVD insertion showed diffuse

Cite this article: Infinger LK, Varma AK (2014) HSV-2 Meningitis Presenting with Acute Hydrocephalus Ultimately Requiring Long Term CSF Diversion. JSM
Neurosurg Spine 2(1): 1012.
Infinger et al. (2014)


leptomeningeal and ependymal enhancement, but no organized undergo successful wean of the ventricular drain. A ventricular-
infiltrative lesions (Figures 2 and 3). There was disproportionate peritoneal shunt (VPS) was placed and she was discharged in a
dilatation of third and lateral ventricles compared to the fourth stable condition
ventricle. Spinal fluid cytology was negative for malignant cells.
There was no evidence of active herpetic genital or oral lesions.
There was no evidence of lymphoma. She received treatment Viral meningitis is characterized, as the name suggests, by
for HSV-2 meningitis with acyclovir for 21 days. The infection inflammation of the meninges. The common clinical features
cleared as evidenced by negative HSV PCR, but she was unable to include fever, headache, and stiff neck. In encephalitis the
brain parenchyma is also involved and causes alteration of
consciousness, focal neurologic signs, and seizures [5]. HSV-
1 is commonly associated with oral lesions, and HSV-2 is more
often associated with genital lesions. OSullivan et al. have also
reported primary HSV-2 CNS infection in absence of active or
prior history of genital lesions [6].
Hydrocephalus is known sequelae of meningitis. It is most
often seen following bacterial and tubercular meningitis [7].
High protein levels, high cell count in the CSF, and cisternal
exudates impede CSF circulation leading to development of
hydrocephalus. The incidence of post meningitic hydrocephalus
is reportedly 50% - 80% following tubercular meningitis [8],
Figure 1 Axial non-contrasted CT scan demonstrating acute hydrocephalus
and 2% - 18% [9-10] in children and up to 38% in the elderly
with transependymal flow.
[11] following bacterial meningitis. Viral infection is a rare
cause of post meningitic hydrocephalus presumably due to
significantly lower protein, and cell content in CSF, and absence
of basilar cistern exudates. HSV accounts for 1%-3% of all viral
meningitis [12]. Hydrocephalus following viral meningitis has
been reported after lymphocytic choriomeningitis virus infection
[13] and mumps meningoencephalitis [14]. Hydrocephalus due
to HSV-2 meningitis is rarely seen in adults, and has only been
reported in one other case in two different publications [15,16].
A single case of post intracranial surgery HSV-1 meningitis with
hydrocephalus has also been reported [17]. The pathogenesis
of hydrocephalus after HSV-2 meningitis remains unclear. Post
mumps meningoencephalitis hydrocephalus has been shown to
result from aqueductal stenosis [14]. There is not enough evidence
to support similar mechanism in HSV2 meningitis associated
Figure 2 Axial T1 MRI with contrast demonstrating completed after placement hydrocephalus. Though, MRI findings of ependymal enhancement
of and external ventricular drain showing diffuse abnormal leptomeningeal and
along the ventricles and aqueduct with disproportionate dilation
ependymal enhancement but no organized infiltrative lesions.
of third and lateral ventricles compared to fourth ventricle seem
to suggest a role for aqueductal stenosis in the present case.
Heppner et al. also noted a relatively small fourth ventricle in
their report of post HSV-2 meningitis hydrocephalus [16].
Diagnosis of hydrocephalus secondary to HSV-2 meningitis is
difficult and may not be recognized by the clinician because of
the rarity of condition. Our patient was treated for dehydration
and released by an outside hospital prior to the correct diagnosis
being made. Neuroimaging in HSV meningitis is not diagnostic,
but clearly has a role in early detection of sequelae and
complications. Leptomeningeal and ependymal enhancement
on MRI and CT indicates an inflammatory process, but further
testing is required to establish diagnosis. Amplification of HSV
genome by Polymerase Chain Reaction (PCR) of the CSF is the
diagnostic method of choice PCR has >95% sensitivity and
specificity for HSV DNA in the first week after treatment onset for
Figure 3 Coronal T1 MRI with contrast demonstrating completed after
placement of and external ventricular drain showing diffuse abnormal
patients with encephalitis [18].
leptomeningeal and ependymal enhancement but no organized infiltrative
Unlike HSV encephalitis, the role of antiviral therapy in HSV2
meningitis is not clearly defined. The patient case reported

JSM Neurosurg Spine 2(1): 1012 (2014)

Infinger et al. (2014)


by Heppner et al. recovered without antiviral therapy. In the Patel R. Clinical spectrum and laboratory characteristics associated
absence of clear guidelines, we would recommend managing with detection of herpes simplex virus DNA in cerebrospinal fluid.
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Cite this article

Infinger LK, Varma AK (2014) HSV-2 Meningitis Presenting with Acute Hydrocephalus Ultimately Requiring Long Term CSF Diversion. JSM Neurosurg Spine 2(1):

JSM Neurosurg Spine 2(1): 1012 (2014)