Herpes simplex virus type 2 (HSV-2) is a well-established cause of encephalitis and is less commonly associated with ischemic stroke. Here we report a case that presented as recurrent acute ischemic strokes followed by bilateral intracerebral hemorrhages (ICH) as a complication of HSV-2 encephalitis.

Case report

A 56-year-old male with a history of HIV and fully-treated neurosyphilis without residual neurologic deficits presented with altered mental status, aphasia and right-sided weakness after being found down at home. An MRI brain showed bilateral anterior and posterior circulation subcortical acute and subacute ischemic strokes as well as a small left thalamic ICH. He remained afebrile, hemodynamically stable, and without leukocytosis. He had negative blood cultures and a normal echocardiogram. A lumbar puncture was performed after initial screening failed to reveal the stroke etiology. Cerebral spinal fluid (CSF) analysis revealed a lymphocytic leukocytosis, with elevated protein and was positive for HSV-2; no other infection was detected in the sample. The first week of his admission his mental status progressively deteriorated, and repeated imaging reported acute bilateral intracranial hemorrhages, with severe brain edema. He was treated with IV Acyclovir and high-dose steroids with no improvement, so he was transitioned to comfort focused measures and discharged on home hospice.

HSV-2 encephalitis is a less frequently described cause of ischemic stroke. Prior case reports highlight immunocompromised hosts presenting with aphasia, progressive altered mental status, and multiple subcortical ischemic and hemorrhagic infarctions. It is important to recognize this etiology of stroke and ICH, as diagnosis and treatment for HSV-2 encephalitis may be delayed during routine hospital work-up for stroke.