Atypical Presentation of Herpes Simplex Virus Type 1 Meningoencephalitis With Nonclassical Imaging in a Young Adult
Bibliographic record
Abstract
Herpes simplex virus type 1 (HSV-1) is a leading cause of viral meningoencephalitis. Clinical management requires timely diagnosis and treatment, yet early detection can be hindered by atypical imaging and antiviral resistance with rapid neurological decline. We report a case of a 35-year-old previously healthy man, who developed subacute headache, fever, and altered mental status following recent travel. Initial cerebrospinal fluid (CSF) analysis showed elevated protein and red blood cells without significant pleocytosis. Repeat lumbar puncture (LP) returned positive HSV-1 polymerase chain reaction (PCR) and elevated opening pressures. Despite empiric antiviral therapy and intravenous immunoglobulin, his condition rapidly deteriorated requiring intubation, lumbar drainage, and hypertonic therapy. Magnetic resonance imaging (MRI) showed cortical ribboning on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences without classical frontotemporal involvement. Initial treatment resistance and suspicion for autoimmune encephalitis prompted early initiation of plasma exchange, intravenous immunoglobulin and steroids. Despite aggressive management, the patient progressed to septic shock and multiorgan failure, ultimately transitioning to comfort care. This case highlights the diagnostic and therapeutic challenges in HSV-1 meningoencephalitis with atypical imaging, nonclassical CSF findings, and lack of response to multimodal treatment regimes. It underscores the importance of maintaining a broad differential, initiating early empiric therapy, and integrating serial imaging and repeat diagnostics in cases of rapid neurological decline. Early consideration of autoimmune encephalitis and timely immunotherapy may be warranted when clinical features are ambiguous. HSV-1 encephalitis should remain high on the differential even when classical radiographic and laboratory markers are absent.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".