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Herpes simplex virus type 1 (HSV-1) is an ubiquitous alpha herpesvirus known for its neurovirulence. Encephalitis and meningitis are the commonest neurological manifestations while ocular infections occur in less than 5% of patients. Reported ophthalmologic complications range from conjunctivitis to acute retinal necrosis. Thus far HSV-1 infection leading to isolated papilledema has not been reported.   

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A 24-year-old previously healthy female presented with a 3-day history of headache, intermittent blurring of vision and diplopia. She denied having fever, photophobia, or photophobia. Seizures were not reported, and conscious level remained unaltered. Systems inquiry was unrevealing. Upon evaluation she was found to have gross papilledema with right sided abducens nerve palsy. Visual acuity was 6/6 bilaterally at the point of examination with an enlarged blind spot on perimetry. There were no signs of meningism nor any other neurological deficits. Her blood pressure was 110/70 mmHg with an unremarkable general examination and a BMI of 19.7kg/m². Basic investigations including inflammatory markers were normal. There was no background slowing on electroencephalography. MRI of the brain and orbits was also normal. The opening pressure of 90 mmH₂O obtained on manometry is likely to have been modified by use of topiramate, prescribed prior to admission. CSF analysis was lymphocytic (23 per high power field) with marginally elevated protein (48 mg/dL) and 5 red cells. There was no hypoglycorrhachia. HSV-1 specific DNA was positive in CSF. She was treated with 14 days of intravenous acyclovir, after which there was complete resolution of papilledema and ophthalmoplegia.

Previously reported viral causes of papilledema include Enterovirus, Varicella, HHV-6, measles, and HIV. Interestingly, intracranial hypertension was demonstrated by manometry in these cases but absent in ours. Workup for papilledema should therefore include search for viral etiologies as they show excellent treatment response.