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Justice
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A 58-year-old man is brought to your office by family members because he has been acting “childish” for 2 days. Today, he spent several hours changing the channels on the remote control, even though the television set was turned off.
On physical examination, temperature is 38.4°C (101.1 °F). He is confused about where he is and what occurred today. There is no meningismus. Funduscopic examination and the remainder of the neurologic examination are normal, as is the general physical examination.
Plasma glucose and serum electrolyte determinations are normal. CT scan of the head without contrast shows no abnormalities. Lumbar puncture is performed. Cerebrospinal fluid shows 84 leukocytes/μL (93% lymphocytes and 7% neutrophils), protein of 90 mg/dL, and glucose of 75 mg/dL (simultaneous plasma glucose is 88 mg/dL).
Which of the following is most appropriate at this time?
A. Begin acyclovir, 5 mg/kg intravenously every 8 hours
B. Begin acyclovir, 10 mg/kg intravenously every 8 hours
C. Await the results of a polymerase chain reaction test of CSF before beginning antiviral therapy
D. Await the results of an MRI scan of the head before beginning antiviral therapy
E. Await the results of a brain biopsy before beginning antiviral therapy
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| Markus2009
Forum Senior
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B------>empiric treatment with acyclovir which is relatively non toxic and because the prognosis of untreated HSE is poor.
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| CocaCola
Forum Guru
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I dont know what dose to give... but begin tx with acyclovir is right!
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| guangyu
Forum Elite
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A or B?
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| Jcala
Forum Junior
Topics: 10
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B ?
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| Drtweetie
Forum Elite
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B. From CMDT: For HSV encephalitis, acyclovir is given intravenously in a dosage of 30 mg/kg per day and continued for 10 to 14 days in order to prevent relapse
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| inkspot
Forum Guru
Topics: 26
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it looks viral and most likely HSV.
im not sure about the dosage though. could be a or b.
you never wait for culture reports and see the patient die. emperical intervention is required.
Off-note:
" changing the channels for 2 hours " ----> never heard of such behaviour in encephalitis patients and why does the family member stop him , is this new entertainment for them 
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| Justice
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The correct answer is B
This patient has encephalitis (fever, confusion, and cerebrospinal fluid showing lymphocytic pleocytosis, elevated protein, and normal glucose). Moreover, the history suggests involvement of the temporal lobe, which is the area most often affected in patients with herpes simplex virus encephalitis. Therapy should not be delayed in order to confirm the etiologic diagnosis because survival in these patients is directly related to the level of consciousness at the onset of treatment. Intravenous acyclovir significantly reduces mortality from herpes simplex virus encephalitis and should be started promptly when this diagnosis is a serious consideration. The dose of acyclovir for this indication is 10 to 15 mg/kg every 8 hours, which is higher than that used for other infections caused by herpes simplex virus.
Intravenous acyclovir at 5 mg/kg every 8 hours is used for systemic herpes simplex virus infections, but this dose is considered inadequate for central nervous system infections. Although a positive polymerase chain reaction test of cerebrospinal fluid may be used to confirm the diagnosis and a negative test may be an indication for discontinuation of empiric therapy, treatment must begin before this result is available. Similarly, therapy should not be delayed to obtain another imaging study. Although brain biopsy had been the standard approach to diagnosis, this invasive test is now reserved for patients who are not responding to therapy or have other indications for neurosurgery, such as the need to evaluate a mass that could be an abscess or a tumor.
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