(755) Herpes Simplex Reactivation: A Rare Case of Fever in the Post-Neurosurgery Patient

Introduction: Herpes simplex virus (HSV) reactivation can be triggered by systemic stressors, including major interventions such as neurosurgery. Clinical presentation often goes unnoticed as manifestation may be limited to fever in the post-operative state. As HSV meningoencephalitis carries significant morbidity and mortality, having a high index of suspicion in the right setting allows early diagnosis and treatment. Less than 50 cases have been documented in the literature, raising the question of this condition being underdiagnosed.

Description: A 39-year-old female with endometrial adenocarcinoma was admitted with an acute ischemic stroke due to a tandem left internal carotid artery – middle cerebral artery occlusion. During mechanical thrombectomy, she developed ipsilateral subarachnoid hemorrhage that prompted decompressive hemicraniectomy with extra-ventricular drain placement. On day 4, hospital course was further complicated by recurrent fevers of unknown source. She was empirically covered with Vancomycin and Cefepime, however repeat blood cultures and urinalysis remained negative. Chest x-ray and secretions were unremarkable on minimal ventilator settings and she required no hemodynamic support. However, she continued to spike fevers with rising leukocytosis. Mental status was confounded by light sedation with Dexmedetomidine. However, she appeared aphasic. Motor responses were only elicited with noxious stimulation, with left extensor posturing, and right withdrawal and some nonpurposeful spontaneous movements. Given concern for healthcare-associated ventriculitis, she underwent cerebrospinal fluid analysis with polymerase chain reaction testing which remarkably returned positive for HSV-2. Antibiotics were discontinued and she was initiated on Acyclovir with brisk resolution of fevers and improvement of mental status to a more meaningful interaction with family and providers. She was eventually transitioned to brain injury unit for inpatient rehabilitation.

Discussion: HSV may remain latent until viral replication is prompted by a sufficient trigger such as a neurosurgical procedure. Our experience highlights the significance of ruling out central nervous system infection as a cause of fever in the post-operative neurosurgical patient population.